F 3.405(J) Financial Affidavit For Court-Appointed Attorney Obligor Name: __________________________ _____________________________ ___ ___ Last First MI Age Spouse (if Married): __________________________ _____________________________ ___ ___ Last First MI Age Address: _______________________________________________________ (____) ______________ Street City State Zip Phone Emergency Contact: Name: ______________________________ ______________________ ___ ___ Last First MI Age Address:_______________________________________________________ (____) ______________ Street City State Zip Phone EMPLOYMENT: I N C O M E Are you (check one): ___Employed ___Unemployed ___Self-employed Complete the information below for the past 12 months: EMPLOYER ADDRESS DATES OF EMPLOYMENT (Your)_____________________________________________________________________________ _____________________________________________________________________________ (Spouse)____________________________________________________________________________ _____________________________________________________________________________ Monthly Income _________________ _________________ Total $ ___________ x 12 Estimated Annual Income: $________________ If living with your parents or others to whom you look for support, enter their monthly income: $________________ OTHER INCOME: Have you received within the past 12 months any other income, including from a business, rent payments, public assistance, support or other sources? ___ Yes ___No If yes, give the amount received and identify sources: _____________________________________________________________________________ _____________________________________________________________________________ CASH: Have you any available cash or money in savings or checking accounts, certificates of deposit or other funds? ____ Yes ____ No O T H E R O B L I G A T I O N S A S S E T S Other Income $_________________ Cash Value $________________ Total Annual Income: $_________________ PROPERTY: Do you own a home, land or other property? (Do not include any household furnishings or clothing) ____ Yes ____ No A. If yes, approximately how much is it worth? B. How much is still owed on it? C. Net value of property (A - B) Property Value $________________ $________________ $________________ Total Income, Other Income, Cash and Property DEPENDENTS: Check one: ___Single ___Married ___Widowed ___Separated ___Divorced Total Number of Dependents: ____ List their names, ages, and relationship to you: _____________________________________________________________________________ _____________________________________________________________________________ & D E B T Debts/Monthly Bills: List your expenses for each of the following categories: Rent/House payment Food/Clothing/Medicine Utilities Alimony/Child Support Installment Payments Other Payments Total Monthly Expenses Monthly Expenses $___________________ $___________________ $___________________ $___________________ $___________________ $___________________ $___________________ American LegalNet, Inc. www.FormsWorkflow.com