THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) AFFIDAVIT OF ASSETS AND LIABILITIES 1. 2. 3. 4. Name: Where do you live? Marital Status: Single Married Separated DOB: Widowed List the names, ages, relationships of dependents you support: 5. If you are presently employed, state where and for how long: Full-Time Part-Time 6. 7. 8. 9. If unemployed, state last date of employment: When do you anticipate new employment? If your spouse is presently employed, state where and for how long? Full-Time If spouse unemployed, state last date of employment: Yours $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ American LegalNet, Inc. www.FormsWorkFlow.com Part-Time 10. List other employed household members and their weekly income: 11. Please state weekly take-home amount Salary/Wages Pension/Trust Benefits Unemployment Compensation Social Security Investment income Alimony Child Support Welfare Payments Other Total 12. What money is presently available to you? Cash on hand Checking account Savings account Stocks/Bonds/IRA/Pension Spouse's Total NHJB-2328-D (12/07/2006) Page 1 of 2 Case Name: Case Number: AFFIDAVIT OF ASSETS & LIABILITIES 13. Please state your monthly household expenses: Rent/Mortgage $ Clothing $ Property Taxes $ Transportation $ (including gas, maintenance, insurance repairs) Heat $ Food $ Other (specify) Utilities $ Medical/Dental $ Insurance $ Total $ 14. List any real estate you own, its market value and the amount you owe: 15. List any vehicles you own (car, truck, boat, motorcycle, snowmobile, RV), their market value and the amount you owe: 16. List income tax paid last year: 17. List income tax refund received last year: 18. Other than monthly household expenses, list any bills you owe, amount owed, to whom, and monthly payment: 19. List which of your bills are court-ordered payments (i.e. alimony, judgment in a law suit, etc.): 20. Other than those previously mentioned, list anyone to whom you owe money, amount and when it is due: 21. If anyone owes you money, state name, address, amount due, and when due: 22. List any property you have transferred within the last three years, to whom and for what price: 23. List any other assets or expenses not previously mentioned: I swear the foregoing information is true and correct to the best of my knowledge under penalties of law. Date NHJB-2328-D (12/07/2006) Signature Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com