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Affidavit Of Financial Condition Form. This is a Nevada form and can be use in Clark County.
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Tags: Affidavit Of Financial Condition, Nevada County, Clark
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AFFT
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DISTRICT COURT
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CLARK COUNTY, NEVADA
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Plaintiff(s),
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CASE NO.
-vs-
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DEPT. NO.
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Defendant(s).
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AFFIDAVIT OF FINANCIAL CONDITION
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Date of Hearing:
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Time of Hearing:
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Judge:
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PART “A” PERSONAL INFORMATION
(PRINT OR TYPE)
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2. Social Security Number:
1.
Name:
3.
Age:
5.
Employer:
6.
City & State of Residence:
7.
Length of time at current job:
4. Occupation:
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8A.
FAMILY RESIDENCE TABLE. In the table below, insert the names and
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ages of each person living primarily with you. Only list persons who live
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with you more than half the time. Check the appropriate box if the person
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named is a child of either marriage/relationship or some other marriage/
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relationship. If the named individual is not a child, specify that person’s
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relationship to (husband, aunt, friend, significant other, etc.). If there are
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more persons living with you than will fit in the table below, attach a sheet
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with the same information for those persons as is set out in the table.
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NAME
AGE
MINOR CHILD
OF THIS
MARRIAGE
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11
MINOR
CHILD
NOT OF THIS
MARRIAGE
OTHER
RELATIONSHIP
(SPECIFY)
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8 B.
living with you more than half of the time, please attach separate sheet
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listing the names and ages of such person(s) and your relationship with
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such person(s). Also, specify any support your actually paying in the
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“Monthly Bills” section of EXHIBIT “A” and specify if your payments are
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voluntary or court ordered.
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If you are supporting (or are obligated to support) any person who is NOT
9.
If you are divorced from the other party in this action, are you
remarried?
Yes
No If so, is your current spouse employed?
Yes
No
What is your spouse’s hourly rate of pay or monthly gross pay if not paid
hourly?
Per
. What is your spouse’s current monthly net
income (i.e. income after deducting federal income taxes, Social Security,
and other INVOLUNTARY deductions? $
ADDITIONAL COMMENTS ABOUT PART “A”:
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PART “B” – MONTHLY INCOME & RECEIPTS
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1. Hourly or other rate of pay: $
per
.
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2.
GROSS (i.e. total) monthly income earned by working from ALL
sources. NOTE: Include overtime and extra job income and
specify here what portion monthly is average overtime: $
or
extra job income: $
.
+$
3.
Court ordered or voluntary payments you receive monthly from the
other party to this action for your own support:
+$
4.
Spousal support or alimony you receive monthly from anyone
OTHER THAN the party to this action: State name(s) of source
you receive this from:
+$
5.
Child support you receive for children of this marriage/relationship.
If you receive this from a source other than the party to this action
state source(s):
+$
6.
Child support you receive for children NOT of this
marriage/relationship. State name(s) of source you receive this
from:
+$
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5
6
7
8
9
10
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12
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8.
TOTAL gross monthly income (total of 1-7):
+$
LESS Federal Income Tax withheld per month (or, if selfemployed, your average monthly Federal Income Tax actually
paid):
-$
10. LESS Social Security withheld per month (or, if self-employed,
your average monthly Social Security or INVOLUNTARY
retirement payment actually paid):
- $
11. LESS any other INVOLUNTARY deductions from your salary (you
must detail on a separate sheet what is in this category and how
much is withheld for each item per month:
-$
12. Your monthly net income (subtract Lines 9, 10 and 11 from Line 8.
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+$
9.
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7. Total from “Other Income” section of EXHIBIT “1” including all
passive income (retirement, pension, or dividend payments, etc.)
and monies or assistance with your monthly expenses received
from other sources (including spouses, relatives, etc.). Note if
there is ANY additional income, you MUST complete the “Other
Income” section of EXHIBIT “1”:
=$
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ADDITIONAL COMMENTS ABOUT “B”
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PART “C” -- MONTHLY EXPENSES
1.
Court ordered or voluntary payments you pay monthly to the
other party for this action for his or her support.
+$
2. Spousal support or alimony you pay monthly to anyone other
than the other party to this action
+$
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3.
Child support you pay for children of this marriage/relationship.
+$
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4.
Child support you pay for children NOT of this
marriage/relationship (specify to whom paid and names and
current ages of these children on attached sheet)
+$
5.
Rent or house payment (principal, interest, taxes, insurance and
+$
6.
Utilities (except telephone):
+$
7.
Telephone (total, but itemized):Basic $
$
Special Features $
8.
Food (total, but itemize): Groceries: $
9.
Clothing (total, but itemize): Self $
3
4
5
8
9
10
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12
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14
Long Distance
+$
Dining Out $
+$
Children $
+$
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10. Laundry and dry cleaning:
+$
11. Average monthly health costs you are paying that are not reimby the other party or insurance
+$
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(total, but itemize below – See Instructions):
MEDICAL DENTAL
OPTICAL PSYCHOLOGICAL
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OTHER
YOURSELF
CHILDREN
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12. Monthly medical insurance premiums you are currently paying:
+$
13. Monthly life insurance premium payment (state if term or whole
)
life:
+$
14. Auto (total, but itemize):
Gas/Oil $
Repair/Maint. $
+$
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Auto Insurance $
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15. Child care expense you are paying: To Whom?
+$
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16. Social, entertainment, and recreation expenses:
+$
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17. Education costs for minor children: Specify:
+$
18. Your monthly education or occupational training costs:
Specify:
+$
+$
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19. Retirement or pension benefits voluntarily withheld per month (for
example IRA, 401K, payroll savings, etc.):
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20. Charitable or religious contributions: Specify:
+$
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21. Personal care (barber, beauty supplies or costs, nails, etc.):
+$
22. Payment of other monthly bills (write monthly total here, but
separately list each creditor, the total owed, the minimum & actual
monthly payments in the “Monthly Bills” section of EXHIBIT “1”):
+$
23. TOTAL MONTHLY EXPENSES (add lines 1 – 22):
=$
24. Surplus or deficit amount. Subtract your total monthly expenses
(Line 23 in Part “C”) from your monthly net income (Line 12 in
Part “2”) and indicate whether the total is a positive number or a
negative number. If you show a deficit amount, (i.e., a negative
number indicating that your monthly expenses exceed your
monthly income) you MUST explain on attached sheet how this
is accomplished:
+/-
25. Other one-time expenses now due (write monthly total here, but
itemize in the “One-Time Expenses Due Now or Within 90 Days”
section of EXHIBIT “1”):
$
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EXHIBIT 1
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SOURCE
AMOUNT
EXPLANATION
INCOME:
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OTHER MONIES RECEIVED:
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TOTAL OTHER INCOME
(Enter on Line 7 of Part “B”)
Note: Use Additional sheet(s) if more Space is Needed
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CREDITOR
MONTHLY BILLS
TOTAL
MINIMUM
OWED
MONTHLY
PAYMENT
ACTUAL
MONTHLY
PAYMENT
EXPLANATION
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5
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7
8
9
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ENTER ON LINE 25 OF PART “C”
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12
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TOTAL MONTHLY BILLS
(Enter on Line 25 Part “C”)
ONE-TIME EXPENSES DUE NOW OR WITHIN 90 DAYS
Note: Use Additional Sheet(s) If More Space is Needed
PART “D” -- ASSETS
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(If you are still married to the other party to this case. Set out in the following table an
itemized list of the property in the possession or under the control) of both you and the
other party. If you are no longer married to the other party to this case, use the
following table to set out all property in your possession or under your control. For each
item listed below, if all information does not fit in the space provided you must attach a
separate page(s) as needed and specify each additional asset, its gross fair market
value, the amount of any secured debt or it, and its net value.
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DESCRIPTION
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1. Cash on hand, in banks, credit
unions, etc. (specify locations and
account number(s) by bank or
institution below or on attached
sheet):
2. Stocks, bonds, notes, deeds of
trust, etc., (specify locations and
account number(s) by company,
holder, etc. below or on attached
sheet):
3. Real Estate (name each
mortgage holder and amount of
each mortgage)
Home:
Other:
4. Automobile #1 Make
Year
Model
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WHO HAS
POSSESSION
GROSS FAIR
MARKET VALUE
AMOUNT OF
SECURE DEBT
NET
VALUE
-
=
-
=
-
=
-
=
5. Automobile #1 Make
Model
Year
-
=
6. Other vehicles, boats, trailers,
etc. (specify below or on attached
sheet):
7. House furniture, furnishings,
and appliances (specify below or
on attached sheet):
8. Life insurance (cash value)
9. Retirement, pension, profitsharing, annuities and IRAs
(specify below or on attached
sheet):
10. Accounts receivable and
pending tax refunds (specify
dates expected to be received
below or on attached sheets):
11. Partnerships and other
business interest (specify below
or on attached sheet)
12. List combined value of all
assets not listed in items 1-11 of
this part with a value of $500.00
or more (Use EXHIBIT “2” to
specify these assets)
TOTAL
-
=
-
=
-
=
=
-
=
-
=
-
=
-
=
NOTE: Use EXHIBIT “2” if additional space is needed for items 1-12 of Part “D”
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ADDITIONAL COMMENTS ABOUT PART “D”:
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EXHIBIT “2”
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DESCRIPTION
WHO HAS
POSSESSION
GROSS FAIR
MARKET VALUE
AMOUNT OF
SECURE DEBT
NET
VALUE
-
=
-
=
-
=
-
=
-
=
-
=
-
=
-
=
-
=
-
=
-
=
-
=
-
=
-
=
-
=
-
=
-
=
21
-
=
22
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=
23
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=
-
=
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TOTAL
Write the Total on Line
12 of Part “D”
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ADDITIONAL COMMENTS ABOUT PART “C”:
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PART “E” ATTORNEY’S FEES & COSTS STATEMENT
As of the date I have signed this form, my attorney has been paid, by me or by
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others on my behalf, $
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attorney(s) for payment of fees and costs in the future is as follows:
for attorney’s fees and costs. My arrangement with my
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__________________________________
Affiant
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OATH
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STATE OF
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COUNTY OF
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)
)
)
ss:
I declare under penalty of perjury under the law of the State of Nevada that the
foregoing is true and correct.
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EXECUTED this
day of
, 20
.
__________________________________
Affiant
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