q District Court _________________________________________ County, Colorado Court Address: In Re: Petitioner: Respondent/Co-Petitioner: COURT USE ONLY Case Number: Attorney or Party Without Attorney (Name and Address): Phone Number: FAX Number: E-mail: Atty. Reg.#: Division FINANCIAL AFFIDAVIT – SIMPLIFIED VERSION Courtroom **THIS FORM MAY BE USED ONLY FOR CASES WITHOUT CHILDREN OR SPOUSAL SUPPORT** (USE THE STANDARD AFFIDAVIT WITH RESPECT TO FINANCIAL AFFAIRS FOR ALL OTHER CASES) Name: Social Security Number: Home Telephone: Work Telephone: I declare under oath that the following is true: 1. I am employed as: 2. Employer’s name, address and phone number: 3. I am employed 4. The amount of each paycheck is $ hours per week. I am paid q weekly q twice a month q monthly. . (Attach your last pay stub and last income tax return.) 5. My monthly income is: $ (To figure this out, take each paycheck amount times number of pay periods per year divided by 12.) JDF 1112 R7/00 FINANCIAL AFFIDAVIT – SIMPLIFIED VERSION Page 1 of 3 2002 © American LegalNet, Inc. 6. The following amounts are taken out of each paycheck monthly: Federal Withholding Tax Social Security: $ PERA: $ Medicare: $ Union Dues: $ Colorado State Tax: $ Charity: $ Life Insurance: $ Stock Purchase: $ Health Insurance: $ Cafeteria Plan: $ 401K Plan: $ Credit Union: $ Other: 7. $ $ Other: $ I get income from other sources, in addition to my main employment. The amount per month is: $ and is from: q Another Job: ($ ) q Unemployment compensation: ($ __________) q SSI: ($ ) q Worker’s compensation: ($ __________) q SSDI: ($ ) q Interest: ($ __________) q Pension/Retirement: ($ ) q Maintenance: ($ __________) q Child Support: ($ ) q Dividends: ($ __________) q Other federal or state benefits: ($ ) 8. My deductions from sources in (7) are (type of deduction and amount): 9. The monthly debts that I am paying are as follows: Creditor Unpaid Balance Monthly Payment 10. The debts acquired during the marriage that I owe, but am not paying on are: Creditor JDF 1112 R7/00 Unpaid Balance FINANCIAL AFFIDAVIT – SIMPLIFIED VERSION Monthly Payment Page 2 of 3 2002 © American LegalNet, Inc. 11. I own the following property : ASSET FAIR DESCRIPTION (Include VIN #s or MARKET any ID #s) VALUE LOAN BALANCE EQUITY PURCHASE DATE NAME TITLED I declare under penalty of perjury that I have read this affidavit and the statements contained in it are true and correct. Date: ____________________________________ ______________________________________ Signature STATE OF COLORADO COUNTY OF: _____________________________ Signed before me under oath on this date: My commission expires: Notary Public [Seal] JDF 1112 R7/00 FINANCIAL AFFIDAVIT – SIMPLIFIED VERSION Page 3 of 3 2002 © American LegalNet, Inc.