STATE OF FLORIDA DIVISION OF ADMINISTRATIVE HEARINGS OFFICE OF THE JUDGES OF COMPENSATION CLAIMS Employee, ) ) Claimant, ) ) vs. ) OJCC Case No. ) Employer, ) Date of Accident: ) Employer/Carrier/Servicing Agent ) ______________________________________) FINANCIAL AFFIDAVIT IN SUPPORT OF VERIFIED PETITION FOR RELIEF FROM PAYING COSTS STATE OF FLORIDA COUNTY OF BEFORE ME this day personally appeared ___________________ ____________________, who, being sworn, deposes and says that the following information is true and correct according to his/her best knowledge and belief: EMPLOYMENT AND MONTHLY INCOME Occupation: ___________________________________________________ Employed By: __________________________________________________ Address: ______________________________________________________ Pay Period: ___________________________________________________ Rate of Pay: __________________________________________________ Bonuses, commissions, allowances, 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) $__________________ American LegalNet, Inc. www.USCourtForms.com>>>> 2 Disability benefits $__________________ Workers compensation benefits $__________________ Unemployment compensation benefits $__________________ Pension, retirement, annuity payments $__________________ Social Security benefits $__________________ Spousal support received from previous marriage $__________________ Interest and dividends $__________________ Rental income (gross receipts minus ordinary and necessary expenses required to produce income) $__________________ Income from royalties, trusts, 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 gains) $__________________ Itemize any other income of a recurring nature $__________________ TOTAL MONTHLY INCOME $__________________ DEDUCTIONS Federal income taxes $__________________ FICA or self-employment tax $__________________ Mandatory union dues $__________________ Mandatory retirement $__________________ Health insurance payments $__________________ Child support payments actually paid $__________________ 2 American LegalNet, Inc. www.USCourtForms.com>>>> 3 TOTAL DEDUCTIONS $__________________ NET MONTHLY INCOME(Total monthly income less total deductions) $__________________ If anyone contributes to your income or helps pay your expenses, complete the following: Name of Relationship to Total Monthly Contributor Claimant/Appellant Amount of Contribution __________________ __________________ $___________________ __________________ __________________ $___________________ __________________ __________________ $___________________ TOTAL $___________________ HOUSEHOLD AND OTHER EXPENSES (Average monthly expenses) Mortgage or rent payments $_______________________ Property taxes and insurance $_______________________ Electricity $_______________________ Water, garbage, and sewer $_______________________ Telephone $_______________________ Fuel oil or natural gas $_______________________ Food and grocery items $_______________________ Other: __________________________ $_______________________ __________________________ $_______________________ __________________________ $_______________________ AUTOMOBILE: 3 American LegalNet, Inc. www.USCourtForms.com>>>> 4Loan payment $_______________________ Auto tags and license $_______________________ Insurance $_______________________ Other $_______________________ INSURANCE: Health $_______________________ Life $_______________________ Other: __________________________ $_______________________ __________________________ $_______________________ Other expenses not listed above: __________________________ $_______________________ __________________________ $_______________________ __________________________ $_______________________ PAYMENTS TO CREDITORS: To Whom Balance Due Monthly Payment ______________________ _______________ _______________ ______________________ _______________ _______________ ______________________ _______________ _______________ ______________________ _______________ _______________ ______________________ _______________ _______________ ______________________ _______________ _______________ TOTAL MONTHLY PAYMENTS TO CREDITORS: $______________________ TOTAL MONTHLY EXPENSES: $______________________ 4 American LegalNet, Inc. www.USCourtForms.com>>>> 5 SUMMARY OF INCOME AND EXPENSES: NET MONTHLY INCOME: $______________________ MONTHLY CONTRIBUTION-OTHERS: $______________________ SUBTOTAL: $______________________ LESS TOTAL MONTHLY EXPENSES $______________________ BALANCE (+ OR -) $______________________ ASSETS (If jointly owned, indicate full value of asset) Cash (on hand or in banks) $______________________ Stocks/bonds/notes $______________________ Real estate: Home $______________________ ______________________ $______________________ ______________________ $______________________ Automobiles: Make Model Year Value ________________ _____________________ $______________________ ________________ _____________________ $______________________ Money held in escrow by your attorney on your behalf $______________________ Other personal property: Contents of home $______________________ Jewelry $______________________ Life insurance cash surrender value $______________________ Other assets: 5 American LegalNet, Inc. www.USCourtForms.com>>>> 6 _______________________________________ $______________________ _______________________________________ $______________________ _______________________________________ $______________________ _______________________________________ $______________________ TOTAL ASSETS: $_________________________ LIABILITIES (if joint, allocate equally and indicate your share) Creditor balance Security ______________________ ________________ $_____________________ ______________________ ________________ $_____________________ ______________________ ________________ $_____________________ ______________________ ________________ $_____________________ ______________________ ________________ $_____________________ TOTAL LIABILITIE