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Financial Affidavit Form. This is a Connecticut form and can be use in Family Statewide.
Tags: Financial Affidavit, JD-FM-6, Connecticut Statewide, Family
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
$
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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)
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