AFFT AFFIDAVIT OF FINANCIAL ABILITY Case No. CASE NO. ____________________________________________________________________ DEPARTMENT ____________________________________________________________________ Dept. No. Plaintiff(s) Name (Name of Plaintiff) Defendant(s) Name -vs- _____________________________________ (Name of Defendant) Name does hereby declare that Applicant is a party to the above matter and is required to attend the Court Education Program pursuant to EDCR 5.07; that Applicant cannot afford to pay the program fee of $30.00; and requests that the Court waive fee. (Check and complete all information that applies.) 1. Address: 2. How many live in the home? __________________________________ Address __________________________________ __________________________________ Adults _____ # Children _____ # Total in Family _____ Total # 3. Applicant is: 4. Other family income: $ Amount Every month; 5. Now compute the total monthly income for the whole household for an average month (after taxes deducted): $______________________________ Total Monthly Income 6. Assets: Savings/ Credit Union $_______ Amount 7. 8. 9. Unemployed Self-Employed Employed as:_____________________________________________________ Occupation Source:_______________________________ Source Checking Account Balance $_____ Amt. 10. Fixed debts: To whom Owed Buying: Renting: Housing: ________________________ Name Purchase Price Per Month ________________________ Name Rent $__________ $__________ ________________________ Name Price Name ________________________ Cars:_____________________________ ________________________ Cars Name ________________________ Name Other property: ______________________ ________________________ Name Describe other __________________________________ ________________________ Name __________________________________ ________________________ Name __________________________________ ________________________ Name Monthly payment _______ Pmt. _______ Pmt. Pmt. _______ Pmt. _______ _______ Pmt. _______ Pmt. Pmt. _______ _______ Pmt. Pmt. _______ Pmt. _______ TOTAL: Total _____ Total _____ Total Total _____ Total _____ _____ Total _____ Total Total _____ _____ Total Total _____ Total _____ TOT. _____ I declare under penalty of perjury under the law of the State of Nevada that the foregoing is true and correct. EXECUTED this Day day of Month , 20 Yr. . ___________________________________ Affiant Afft_Fin_Ability.doc/3/15/2005 American LegalNet, Inc. www.USCourtForms.com