Financial Affidavit / Petition for Consideration of Financial Obligation Please print legibly PETITIONER'S NAME The person named above hereby petitions for remission, reduction or waiver of certain financial obligations for reasons shown in this document. Included, herein, please find a description of all such obligations and the reasons for which special consideration is being sought. Respectfully submitted this ______ day of _______________________, 200_____ _______________________________________________ (Signature ) Petitioner BACKGROUND INFORMATION (Do not list real estate or automobiles here) OBLIGATION ONE DATE OBLIGATION INCURRED: FOR: ORIGINAL AMOUNT AMOUNT PAID: UNPAID BALANCE: #REF! EXPLAIN ANY SPECIAL CIRCUMSTANCES ABOUT THIS OBLIGATION and what, if any, consideration is being sought and why. 1 2 3 OBLIGATION TWO DATE OBLIGATION INCURRED: FOR: ORIGINAL AMOUNT AMOUNT PAID: UNPAID BALANCE: #REF! EXPLAIN ANY SPECIAL CIRCUMSTANCES ABOUT THIS OBLIGATION and what, if any, consideration is being sought and why. 1 2 3 OBLIGATION THREE DATE OBLIGATION INCURRED: FOR: ORIGINAL AMOUNT AMOUNT PAID: UNPAID BALANCE: #REF! EXPLAIN ANY SPECIAL CIRCUMSTANCES ABOUT THIS OBLIGATION and what, if any, consideration is being sought and why. 1 2 3 OBLIGATION FOUR DATE OBLIGATION INCURRED: ORIGINAL AMOUNT FOR: AMOUNT PAID: UNPAID BALANCE: #REF! EXPLAIN ANY SPECIAL CIRCUMSTANCES ABOUT THIS OBLIGATION and what, if any, consideration is being sought and why. 1 2 American LegalNet, Inc. www.FormsWorkflow.com 3 PAGE ! PAGE 2 Financial Affidavit and Petition for Reduction of Financial Obligation I RESPECTFULLY REQUEST REMISSION OR WAIVER OF CERTAIN FINANCIAL OBLIGATION(S) SHOWN BELOW FOR THE REASONS INDICATED: AMOUNT PAID TOTAL OBLIGATIONS BALANCE 1. 2. 3. 4. I HEREBY SUBMIT THIS FORM ALONG WITH PROPER DOCUMENTATION CONCERNING MY INCOME AND EXPENSES. I DO UNDERSTAND THAT MY REQUEST FOR CONSIDERATION IS BASED UPON MY FINANCIAL CIRCUMSTANCES WHICH MUST BE , AND I AGREE TO, DISCLOSE FOR CONSIDERATION OF THIS PETITION. I ALS0 REALIZE THAT I AM REQUIRED TO SUBMIT THOSE ITEMS MARKED BELOW WITH THIS PETITION. ______ 1. MY LAST THREE (3) PAY STUBS ______ 5. IF DISABLED, OFFICIAL PROOF (DISABILITY AWARD LETTER) ______ 3. PROOF OF OTHER INCOME, IF ANY ______ 6. IF RECEIVING SOCIAL SECURITY, STATEMENT OF BENEFITS ______ 2. COPIES OF ALL BILLS REFERENCED ______ 4. COPY OF TAX RETURN -LAST YEAR REQUESTER'S INITIALS: Income and expense considerations are based upon support provided for the petitioner and the persons listed below: How many legal dependents do you have? ________ Please list each dependent, their age and relationship to you. NAME AGE RELATIONSHIP LIVES WITH ME ? Circle Yes or No; if no, with whom? YES NO YES NO YES NO YES NO YES NO YES NO INCOME 1. For those now employed, your current job . . . . Employer's name Address Street Address Date Started: City / State / Zip Date Ending: Date of Last (If scheduled) (If scheduled to end) Raise: Next Review: Position: NUMBER OF HOURS WORKED Telephone # Do you expect a raise New wkly Salary $ Comments (Avg Per Wk) $ Weekly Salary 2. Your previous Job: Employer's name Address Date Started: Street Address Date Ended: ENDED City / State / Zip Reason for Leaving: Position: Number hours worked: LEAVING: $ Avg Per Wk/ Mo (circle one) Telephone # Per Wk / Mo (circle one) Comments 3. Your previous Job: Employer's name Address Date Started: Street Address Date Ended: ENDED Position: City / State / Zip Reason for Leaving: Telephone # LEAVING: $ Per (circle one) Week / Month American LegalNet, Inc. Number hours worked: (Avg Per Wk) www.FormsWorkflow.com Comments:____________________________________________________________________ PAGE 3 Financial Affidavit and Petition for Reduction of Financial Obligation FOR THOSE NOW UNEMPLOYED . . . . Highest level of education / Any special skills_______________________________________________________________________________- Your last employment, when did it stop and why?__________________________________________________________________________________ Why aren't you working? _____________________________________________________________________________________________________ When was the last you ACTIVELY looked for a job?_______________________________________________________________________________Name any employment services and dates you contacted them______________________________________________________________________ Name any job training services and dates you contacted them____________________________________________________________________ Are you getting any assistance from any of the following? If so, please indicate the monthly amounts: $0.00 DISABILITY AFDC CHILD SUPPORT ALIMONY WORKER'S COMPENSATION UNEMPLOYMENT SOCIAL SECURITY FOOD STAMPS PENSION TRUST FUND INVESTMENT DIVIDENDS ANY CLAIMS / SETTLEMENTS (From all Sources shown above) OTHER INCOME WAGES (monthly) TOTAL MONTHLY INCOME: MONTHLY EXPENSES: The amounts of money paid by you for each of the following: HOUSING: HOUSING (Rent/Lease/Mortgage) Person / Company to whom this is paid UTILITIES : Water & Sewage Electric Power Cable Garbage Pickup Telephone Other Utilities Gas UTILITIES AUTO EXPENSES Car Payments Car Insurance Car Maintenance Gasoline AUTO EXPENSES OTHER EXPENSES Child Support Food Medical Insurance Beeper / Pager Alimony Payments Cellular/ Car Phone Medical Expenses Loan Payments Other Payments Internet Service Clothing OTHER EXPENSES Household Expenses School TOTAL EXPENSES: ASSETS: Real Estate (FMV)* Net Real Estate Cash (Not Savings) Stocks/Bonds Checking Acct(s) Retirement Acct(s) Other Assets Net Auto Value Other Assets Less Amount Owed Automobile(s) (FMV)* Less Amount Owed * FMV=Fair Market Value Any Inheritances, Name: Lottery Winnings, Name: Any Legal/Insurance Settlements, Name: Any savings account, Institution: Other Assets not shown above: Other Assets not shown above: American LegalNet, Inc. www.FormsWorkflow.com TOTAL ASSETS: Explain on Page 4 # PAGE 4 Financial Affidavit and Petition for Reduction of Financial Obligation Net Worth Monthly Situation TOTAL ASSETS: TOTAL INCOME: TOTAL LIABILITIES: TOTAL EXPENSES: NET WORTH: $0 NET INCOME: COMMENTS 1. In the space provided below, provide any additional comments for consideration, if any. 2. If your NET INCOME is less than $ 0.00, please explain how you now provide for yourself and for your dependants. Otherwiae, INITIAL below to indicate if you have any additional comments. __________ I HAVE NOTHING FURTHER TO ADD. __________ PLEASE CONSIDER THE FOLLOWING COMMENTS: Assistance provided by:___________________________________________ I swear or affirm that the above is true and correct to the best of my knowledge and belief. Petitioner's Printed Name & Address American LegalNet, Inc. www.FormsWorkflow.com Petitioner's Signature Date PAGE 5 Financial Affidavit and Petition for Reduction of Financial Obligation EVALUATOR'S COMMENTS (Indicate NONE if that is appropriate) Evaluation is the result of thorough review of all data presented here in this form. Evaluator's Printed Printed Name Signature Date (Indicate NONE if that is appropriate) Petitioner's Followup Comments, if any: SIGNATURE PAGE 5 American LegalNet, Inc. www.FormsWorkflow.com & DATE 13. Financial Affidavit (LF) 09-05