Revised 12/2012 IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF KANSAS ) ) Plaintiff(s), ) ) vs. ) Case No. ) ) ) Defendant(s). ) AFFIDAVIT OF FINANCIAL STATUS1 I, , state that I am the plaintiff in this case and that the following information regarding my current financial status is true. I . PERSONAL DATA AND MARITAL STATUS: A. My address: My telephone: My age: B. Single: Married: Separated: Divorced: Spouse=s name: Spouse=s age: Spouse=s address (if different from mine): Spouse=s telephone (if different from mine): 1Access to this document is restricted pursuant to the court=s policy to protect the personal privacy interest of the parties. American LegalNet, Inc. www.FormsWorkFlow.com C. Names of dependents who live with me or who I am legally required to support financially: Ages of dependents: Relationship of dependents to me: Amount of monthly support I give each dependent: II. EMPLOYMENT A. Currently employed? Yes No If currently employed: Name of employer: Address of employer: Employer's telephone: Length of employment: Job title or description: Net (take home) income: Monthly $ or Weekly $ Does employer provide health insurance? Yes No If employer provides health insurance, what kind? American LegalNet, Inc. www.FormsWorkFlow.com 3 B. Previous Employment (answer only if currently unemployed) . Name of employer: Address of employer: Employer's telephone: Length of employment: Job title or description: Net (take home) income: Monthly $ or Weekly $ C. Employment of spouse: Name of employer: Address of employer: Employer's telephone: Length of employment: Job title or description: Net (take home) income: Monthly $ or Weekly $ III. FINANCIAL STATUS A. Do you or your spouse own real property? Yes No If yes -Description: Address: In whose name: Estimated value $ Total amount owed $ Owed to: Annual income from property $ American LegalNet, Inc. www.FormsWorkFlow.com 4 B. Do you or your spouse own any automobiles? Yes No If yes, number of automobiles owned: Make Model Year Make Model Year In whose name registered: Present value $ Amount owed on the automobile(s) $ Owed to: Monthly payment(s) $ C. Total amount of cash on hand, in my checking account(s) or savings account(s): $ If not joint account(s) with my spouse, total amount in my spouse=s checking account(s) or savings account(s): $ D. In the last 12 months, have you or your spouse received any money from any of the following sources? Yes No Amount Unemployment benefits: $ Welfare payments: $ ADC or other governmental child support: $ Social Security benefits: $ Pensions, trust funds, annuities or life insurance payment: $ Other gov=t sources (example- Medicaid benefits): $ American LegalNet, Inc. www.FormsWorkFlow.com 5 Gifts or inheritances: $ Other sources (example-judgments in other cases or insurance proceeds): $ IV. OBLIGATIONS A. Monthly mortgage or rental payment on house or apartment $ B. Monthly mortgage payment(s) on other properties $ Amount of equity in other properties $ C. Monthly household expenses: Grocery expense $ Gas $ Electric $ Cable $ Phone (includes cell) $ Water $ Car Insurance $ Health Insurance $ Life Insurance $ D. Other monthly debts and miscellaneous expenses (examples-credit cards, medical bills, alimony, child support, student loans, tax lien or other gov=t liability). To whom owed and for what reason incurred: Monthly Balance Due Payment American LegalNet, Inc. www.FormsWorkFlow.com 6 V. OTHER INFORMATION PERTINENT TO FINANCIAL STATUS: A. Have you ever filed for bankruptcy? Yes No B. Information regarding stocks, bonds, savings bonds, either owned individually or jointly. I understand that a false statement or answer to any question in this affidavit will subject me to penalties of perjury. Signature of Plaintiff Name (Print or Type) Address City State Zip Code Telephone American LegalNet, Inc. www.FormsWorkFlow.com