1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 AFFT Name (Attorneys Include Bar No. & Firm) ___________________________________________________ ___________________________________________________ Address ___________________________________________________ City, State, Zip ___________________________________________________ Telephone ___________________________________________________ In Proper Person or Attorney for. DISTRICT COURT CLARK COUNTY, NEVADA Plaintiff(s) ____________________________________________ ____________________________________________ Plaintiff(s), -vsDefendant(s) ________________________________ ________________________________ Case No. CASE NO. ______________ Dept. No. DEPT. NO.______________ Defendant(s). AFFIDAVIT OF FINANCIAL CONDITION Hearing Date Date of Hearing:____________________________ Time of Hearing:____________________________ Hearing Time Judge: ____________________________________ Judge PART "A" PERSONAL INFORMATION (PRINT OR TYPE) 1. 3. 5. 6. 7. Name: Name 2. Social Security Number: _____________ SSN Age Age:_______ 4. Occupation: ________________________________________ Occupation Employer:________________________________________________________ Employer City & State of Residence:___________________________________________ City & State Length of time at current job: _________________________________________ How Long ______ INITIAL Afft_Fin_Cond.doc/3/15/2005 American LegalNet, Inc. www.USCourtForms.com 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 8A. FAMILY RESIDENCE TABLE. In the table below, insert the names and ages of each person living primarily with you. Only list persons who live with you more than half the time. Check the appropriate box if the person named is a child of either marriage/relationship or some other marriage/ relationship. If the named individual is not a child, specify that person's relationship to (husband, aunt, friend, significant other, etc.). If there are more persons living with you than will fit in the table below, attach a sheet with the same information for those persons as is set out in the table. NAME AGE MINOR CHILD OF THIS MARRIAGE MINOR CHILD NOT OF THIS MARRIAGE OTHER RELATIONSHIP (SPECIFY) Relationship Name Name Name Age Yes or No Yes or No Yes or No Yes or No Yes or No Yes or No Age Age Age Age Relationship Relationship Relationship Relationship Name Name 8 B. Yes or No Yes or No Yes or No Yes or No If you are supporting (or are obligated to support) any person who is NOT living with you more than half of the time, please attach separate sheet listing the names and ages of such person(s) and your relationship with such person(s). Also, specify any support your actually paying in the "Monthly Bills" section of EXHIBIT "A" and specify if your payments are voluntary or court ordered. 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 Period hourly? ________Per__________. What is your spouse's current monthly net Rate income (i.e. income after deducting federal income taxes, Social Security, and other INVOLUNTARY deductions? $_____________ Amount _______ INITIAL Afft_Fin_Cond.doc/3/15/2005 American LegalNet, Inc. www.USCourtForms.com 2 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 ADDITIONAL COMMENTS ABOUT PART "A":________________________________ Comments ______________________________________________________________________ ______________________________________________________________________ PART "B" ­ MONTHLY INCOME & RECEIPTS 1. Hourly or other rate of pay: $_________ per_____________. Rate Period 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 Amount extra job income: $____________. Amount Court ordered or voluntary payments you receive monthly from the other party to this action for your own support: 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: ________________________________ Name(s) _________________________________________________ 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): _______________________________________ Name(s) ____________________________________________________ Child support you receive for children NOT of this marriage/relationship. State name(s) of source you receive this from: _______________________________________________ Name(s) ____________________________________________________ + $_____ Amt. 3. 4. + $_____ Amt. + $_____ Amt. 5. + $_____ Amt. 6. + $_____ Amt. 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": 8. 9. 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): + $_____ Amt. + $_____ Amt. - $_____ Amt. 10. LESS Social Security withheld per month (or, if self-employed, your average monthly Social Security or INVOLUNTARY retirement payment actually paid): - $_____ Amt. 3 _______ INITIAL Afft_Fin_Cond.doc/3/15/2005 American LegalNet, Inc. www.USCourtForms.com 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 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. - $_____ Amt. Amt. = $_____ ADDITIONAL COMMENTS ABOUT "B" ______________________________________ Comments ______________________________________________________________________ ______________________________________________________________________ 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. + $_____ Amt. + $_____ Amt. + $__