IN THE CIRCUIT COURT OF THE SEVENTH JUDICIAL CIRCUIT, IN AND FOR ST. JOHNS COUNTY CASE NO: DIVISION: PETITIONER:____________________________________________ -VSRESPONDENT:___________________________________________ FINANCIAL AFFIDAVIT Petitioner swears and says under penalty of perjury the following is true: Occupation: ______________________________ Business Address:_______________________________ Employed by: __________________________________Pay period: ____________________________________ ITEM 1: INCOME: Average per week, month or bi-weekly (circle). Average Gross wage Deduct Federal Income Tax Social Security Other Total Deductions $ ___________ $ ___________ $ ___________ $ ___________ $ ___________ Average NET wage (Gross less deductions) Other Income: $ __________ $ ___________ TOTAL NET INCOME: $ ___________ ITEM 2: ASSETS: Cash on hand or in banks Stocks, Bonds, notes, etc: $___________ $ ___________ Real Estate: Home Other Automobile(s) Other Personal Property Other Assets: ______________________ TOTAL ASSETS: $ ___________ $ ___________ $ ___________ $___________ $ ___________ $ ___________ $ ___________ ITEM 3: LIABILITIES: Real Estate mortgages Automobile loans Other notes and loans Other: $ ___________ $ ___________ $ ___________ $___________ TOTAL LIABILITIES: Sworn to and subscribed before me this CHERYL STRICKLAND CLERK OF THE CIRCUIT COURT BY: day of $ ___________ _________________________________ Affiant , 20 . (SEAL) CC FORM 4311, REVISED MAR 97 American LegalNet, Inc. www.USCourtForms.com