IN THE COUNTY COURT OF THE TENTH JUDICIAL CIRCUIT IN AND FOR POLK COUNTY, FLORIDA CASE NO. ____________________________ _________________________________________, Affiant. FINANCIAL AFFIDAVIT AND AFFIDAVIT OF INSOLVENCY I, ____________________________________, after being properly placed under oath, do swear or affirm that I have no money or means to pay the filing fee and costs associated with my lawsuit; that I believe my lawsuit asks the Court for relief to which I am legally entitled; and that the following information is true and correct. I understand that if the information I provide below misleads the Court in determining my insolvency, I may be subject to contempt of court or charged with the crime of perjury. EMPLOYMENT AND INCOME OCCUPATION: __________________________________________ SOC. SEC. #: ______________________________________ EMPLOYED BY: __________________________________________ PAY PERIOD: ______________________________________ ADDRESS: __________________________________________ RATE OF PAY: ______________________________________ __________________________________________ AVERAGE GROSS MONTHLY INCOME FROM EMPLOYMENT $_____________ Bonuses, commissions, allowance, overtime, tips $_____________ and similar payments Business income from sources such as self-employment, partnership, close corporations, and/or independent contracts (gross receipts minus ordinary and necessary expenses required to produce income) _____________ benefits Disability _____________ Worker’s Compensation _____________ Unemployment _____________ Compensation Pension, Retirements and Annuity Payments _____________ Social Security _____________ Benefits Spousal Support _____________ Received Interest and _____________ from Previous Marriage Dividends Rental Income (gross receipts minus ordinary and necessary expenses required to produce income) _____________ 2000 © American LegalNet, Inc. Income from Royalties, trust or estates _____________ Reimbursed expenses and in kind payments to the extent that they reduce personal living expenses _____________ Gains derived from dealing in property (not including non-recurring gain) _____________ Itemize any other income of a recurring nature _____________ TOTAL MONTHLY $_____________ INCOME LESS DEDUCTIONS: $_____________ Federal, state and local income taxes (corrected for filing sums and actual number of withholding allowances) _____________ FICA of self-employment tax (annualized) _____________ Mandatory union dues _____________ Mandatory retirement _____________ Health Insurance Payments _____________ Court ordered support payments for the children actually paid _____________ TOTAL DEDUCTIONS $_____________ AVERAGE MONTHLY EXPENSES HOUSEHOLD: Mtg. or rent payments INSURANCES: _______________________ Property taxes & insurance _______________________ $_____________ Electricity _____________ _______________________ Water, garbage & sewer _______________________ _____________ Telephone Fuel Oil or natural gas _______________________ _______________________ Health Life Other Insurance _______________________________________ _______________________________________ Repairs and Maintenance _______________________ Lawn and pool care _______________________ OTHER EXPENSES NOT LISTED ABOVE Pest Control _____________ _______________________ Dry cleaning and laundry Misc. Household _____________ _______________________ Affiant’s clothing 2000 © American LegalNet, Inc. Food and grocery items _____________ _______________________ Meals outside home _____________ _______________________ Other _____________ _______________________ ____________________ _______________________ _____________ AUTOMOBILE: Gasoline and _____________ Affiant’s medical/dental Prescriptions Affiant’s beauty parlor Affiant’s gifts (special holidays) PETS: oil ___________________ Repairs _____________ ___________________ Auto tags and license _____________ ___________________ Grooming Insurance ___________________ Other: _____________ ___________________ ______________________________________ _____________ ______________________________________ _____________ Veterinarian Membership Dues: Professional Dues: Social _____________ Dues: Entertainment Vacations Publications _____________ Charities _____________ CHILDREN’S EXPENSES: Nursery or babysitting ___________________ School tuition _____________ School supplies Lunch Money _____________ Allowance Clothing _____________ ___________________ ___________________ ___________________ ___________________ ___________________ Miscellaneous Other _________________________________ _____________ _________________________________ _________________________________ _____________ _________________________________ Medical, dental prescription ___________________ Vitamins $_____________ ___________________ TOTAL ABOVE EXPENSES: Barber/beauty parlor ___________________ 2000 © American LegalNet, Inc. Cosmetics/toiletries ___________________ Gifts for special holiday ___________________ Other ___________________ PAYMENTS TO CREDITORS: TO WHOM BALANCE MONTHLY DUE PAYMENT _______________________________ _____________ _____________ _______________________________ _____________ _____________ _______________________________ _____________ _______________________________ _____________ _____________ _____________ Total Monthly Payments to Creditors $_____________ TOTAL MONTHLY EXPENSES $_____________ ITEM 3: ASSETS (Ownership: if joint, allocate equally) Description Cash (on hand or in banks) ______________________ Stocks/bonds/notes ______________________ Value Husband Wife __________________ _______________________ __________________ _______________________ Real Estate: Home: _____________________ __________________ _______________________ ________________________________________ ______________________ __________________ _______________________ ________________________________________ ______________________ __________________ _______________________ Automobiles: ________________________________________ ______________________ __________________ _______________________ ________________________________________ ______________________ __________________ _______________________ Other Personal Property: Contents of Home ______________________ __________________ _______________________ Jewelry _________________ _______________________ 2000 © American LegalNet, Inc. ______________________ Life Ins./cash surrender value ______________________ __________________ _______________________ Other Assets ________________________________________ ______________________ __________________ _______________________ ________________________________________ ______________________ __________________ _______________________ TOTAL ASSETS $______________________ $__________________ $_______________________ ITEM 4: Liabilities LIABILITIES Creditor Security Balance Wife Husband ________________________________________ ______________________ __________________ _______________________ ________________________________________ ______________________ __________________ _______________________ ________________________________________ ______________________ __________________ _______________________ TOTAL LIABILITIES $______________________ $__________________ $_______________________ ______________________________________________ Affiant Subscribed and sworn to before me this ______ day of _____________________, 20____ RICHARD M. WEISS, Clerk By_____________________________________ _____ Personally Known _____ Produced Identification Deputy Clerk OR By_____________________________________ _____________________________ Type of identification presented: Notary Public My Commission expires ____________________ 178.doc (07/97) 2000 © American LegalNet, Inc.