FINANCIAL AFFIDAVIT STATE OF CONNECTICUT SUPERIOR COURT JD-FM-6 Rev. 1-08 P.B. 25-30 www.jud.ct.gov FOR THE JUDICIAL DISTRICT OF COURT USE ONLY FINAFF DOCKET NO. AT (Address of court) NAME OF AFFIANT (Person submitting this form) NAME OF CASE PLAINTIFF DEFENDANT NAME OF EMPLOYER OCCUPATION ADDRESS OF EMPLOYER A. WEEKLY INCOME FROM PRINCIPAL EMPLOYMENT (Use weekly average not fewer than 13 weeks) DEDUCTIONS (Taxes, FICA, etc.) AMOUNT/WEEK 1. $ 4. DEDUCTIONS (Cont ) AMOUNT/WEEK $ 2. $ 5. $ TOTAL DEDUCTIONS $ 3. $ 6. $ NET WEEKLY WAGE $ GROSS WKLY WAGE FROM PRINCIPAL EMPLOYMENT $ B. ALL OTHER INCOME (Include in-kind compensation, gratuities, rents, interest, dividends, pension, etc.) 1. WEEKLY INCOME SOURCE OF INCOME GROSS AMT/WK $ 1. DEDUCTIONS AMOUNT/WEEK SOURCE OF INCOME GROSS AMT/WK $ 2. DEDUCTIONS GROSS WEEKLY INCOME FROM OTHER SOURCES $ AMOUNT/WEEK $ $ TOTAL DEDUCTIONS $ $ $ NET WEEKLY INCOME FROM OTHER SOURCES $ $ $ $ $ $ $ ADD "NET WEEKLY WAGE" FROM SECTION A, AND "NET WEEKLY INCOME" FROM SECTION B, AND ENTER TOTAL BELOW: $ $ A. Gas/Oil $ 11. DAY CARE Repairs $ 12. OTHER (specify below) Auto Loan $ $ $ $ $ $ $ $ $ $ 1. RENT OR MORTGAGE $ 2. REAL ESTATE TAXES $ Fuel $ Electricity 2. WEEKLY EXPENSES 3. UTILITIES $ Gas $ Water $ 6. TRANSPORTATION Telephone $ Trash Collection 7. INSURANCE PREMIUMS Public Trans. Medical/ Dental Automobile Homeowners TOTAL NET WEEKLY INCOME $ $ $ Life $ $ Cable T.V. $ 8. MEDICAL/DENTAL $ $ 9. CHILD SUPPORT 4. FOOD $ (order of court) 10. ALIMONY 5. CLOTHING $ (order of court) AMOUNT OF CREDITOR (Do not include mortgages or loan DEBT balances that will be listed under assets.) $ $ B. $ BALANCE DUE TOTAL WEEKLY EXPENSES $ WEEKLY PAYMENT DATE DEBT INCURRED $ $ $ 3. LIABILITIES (DEBTS) $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ C. TOTAL LIABILITIES (Total Balance Due on Debts) (continued) $ TOTAL WEEKLY D. LIABILITY EXPENSE $ American LegalNet, Inc. www.FormsWorkflow.com ADDRESS VALUE (Est ) A. Real Estate ADDRESS EQUITY $ $ VALUE (Est ) ADDRESS MORTGAGE EQUITY $ Other: $ $ VALUE (Est ) YEAR MAKE MORTGAGE EQUITY $ Other: B. Motor Vehicles MORTGAGE $ Home $ $ YEAR MAKE VALUE MODEL MODEL LOAN BALANCE EQUITY $ Car 1: $ $ VALUE LOAN BALANCE EQUITY $ Car 2: $ $ DESCRIBE AND STATE VALUE OF EACH ITEM TOTAL VALUE C. Other Personal Property $ BANK NAME, TYPE OF ACCOUNT, AND AMOUNT TOTAL BANK ACCOUNTS D. Bank Accounts 4. ASSETS $ NAME OF COMPANY, NUMBER OF SHARES, AND VALUE TOTAL VALUE E. Stocks, Bonds Mutual Funds $ NAME OF INSURED COMPANY FACE AMOUNT AMT. OF LOAN $ $ $ $ $ $ $ F. Insurance (exclude children) CASH VALUE $ $ TOTAL VALUE $ NAME OF PLAN (Individual I.R.A., 401K, Keogh, etc ) AND APPROX. VALUE TOTAL VALUE (less loans) G. Deferred Compensation Plans $ TOTAL VALUE H. All Other Assets $ E. I. Total 5. HEALTH INSURANCE $ TOTAL CASH VALUE OF ALL ASSETS NAME AND ADDRESS OF HEALTH OR DENTAL INSURANCE CARRIER (Do not include policy number) NAME(S) OF PERSON(S) COVERED BY THE POLICY SUMMARY (Use the amounts shown in boxes A thru E of sections 1-4.) TOTAL NET WEEKLY INCOME (A) $ TOTAL CASH VALUE OF ASSETS (E) $ TOTAL WEEKLY EXPENSES AND LIABILITIES (B + D) $ TOTAL LIABILITIES (TOTAL BALANCE DUE ON DEBTS) (C) $ CERTIFICATION I certify that the foregoing statement is true and accurate to the best of my knowledge and belief. SIGNED (Affiant) Subscribed and sworn DATE to before me on SIGNED (Notary, Comm. of Superior Court, Assistant Clerk) JD-FM-6 Rev. 1-08 (Back) American LegalNet, Inc. www.FormsWorkflow.com