THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) STATEMENT OF ASSETS AND LIABILITIES FOR INDIVIDUALS AND SOLE PROPRIETORS 1. Name: DOB: 2. Residence Address: 3. Mailing Address (if different): 4. Marital Status: Single Married Separated Widowed 5. List the names, ages, relationships of dependents you support: 6. If you are presently employed, state where and for how long: Full-Time Part-Time 7. If unemployed, state last date of employment: 8. When do you anticipate new employment? 9. If your spouse is presently employed, state where and for how long? Full-Time Part-Time 10. If spouse unemployed, state last date of employment: 11. List other employed household members and their weekly income: 12. Please state weekly take-home amount Yours Spouse222s Salary/Wages $ $ Child Support $ $ Alimony $ $ Trust Benefits $ $ Investment Income $ $ Other $ $ *Social Security $ $ *Welfare Benefits $ $ *Veteran222s Benefits $ $ *Pension $ $ **Unemployment Compensation $ $ **Worker222s Compensation $ $ Total $ 13. What money is presently available to you? Cash on hand .............................................................................................. $ Checking account ........................................................................................ $ Savings account .......................................................................................... $ Stocks/Bonds/IRA/Pension .......................................................................... $ Total $ NHJB-4002-Se (07/01/2018) Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: STATEMENT OF ASSETS AND LIABILITIES FOR INDIVIDUALS AND SOLE PROPRIETORS 14. Please state your monthly household expenses: Rent/Mortgage $ Cell Phone $ Property Taxes $ Clothing $ Heat $ Transportation $ Food $ (including gas, maintenance, insurance, repairs) Utilities $ Other (specify) Medical/Dental $ $ Insurance $ $ Total $ 15. List any real estate you own, its market value and the amount you owe: 16. List any vehicles you own (car, truck, boat, motorcycle, snowmobile, RV), their market value and the amount you owe: 17. List income tax paid last year: $ 18. List income tax refund received last year: $ 19. Other than monthly household expenses, list any bills you owe, amount owed, to whom, and monthly payment: 20. List which of your bills are court-ordered payments (i.e. alimony, judgment in a law suit, etc.): 21. Other than those previously mentioned, list anyone to whom you owe money, amount and when it is due: 22. If anyone owes you money, state name, address, amount due, and when due: 23. List any property you have transferred within the last three years, to whom and for what price: 24. List any other assets or expenses not previously mentioned: * Exempt income 226 The Court may not consider this income. If this represents the sole source of income, the court may not issue a payment order. ** Potentially/partially exempt income 226 The Court may be unable to consider this income. Based upon the facts of the case, the Court may or may not issue a payment order. NHJB-4002-Se (07/01/2018) Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: STATEMENT OF ASSETS AND LIABILITIES FOR INDIVIDUALS AND SOLE PROPRIETORS For non e-filed cases: I state that on this date I am mailing by U.S. mail, or Email (only when there is a prior agreement of the parties to use this method), or hand delivering a copy of this document to: Other party Other party222s attorney OR For e-filed cases: I state that on this date I am sending a copy of this document as required by the rules of the court. I am electronically sending this document through the court222s electronic filing system to all attorneys and to all other parties who have entered electronic service contacts (email addresses) in this case. I am mailing or hand-delivering copies to all other interested parties. Name of Filer Signature of Filer Date Law Firm, if applicable Bar ID # of attorney Telephone Address E-mail City State Zip code NHJB-4002-Se (07/01/2018) Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: STATEMENT OF ASSETS AND LIABILITIES FOR INDIVIDUALS AND SOLE PROPRIETORS Notice of Protected (Exempt) Sources of Income PERIODIC PAYMENTS CANNOT BE ORDERED FROM THE FOLLOWING SOURCES OF INCOME (subject to some exceptions): Social Security Old-Age, Survivors & Disability Insurance Benefits (42, U.S.C. 247 407) Supplementary Security Income (SSI) for the Aged, Blind and Disabled (42 U.S.C. 247407 and 2471383(d)(1)) Unemployment Compensation Benefits (RSA 282-A:159) (Exemption from payment orders except debts incurred for basic needs expenses for you or your family during the period of unemployment. Public Assistance Payments to the Blind, Aged or Disabled Persons and Dependent Children (ANB, OAA, APTD and TANF/FANF) (RSA 167:25) Veterans Benefits including: Retirement Benefits (10 U.S.C. 2471440), Survivors222 Benefits (10 U.S.C. 2471450), Other Veterans Benefits (38 U.S.C. 247 5301(a)), Medal of Honor Veterans Benefits (38 U.S.C. 247 1562) Workers Compensation Benefits (RSA 281-A:52) (Exemption from payment orders except debts for medical and related care for the compensated injury and claims for legal fees approved by the Superior Court for prosecuting the workers compensation claim. Retirement funds including Individual Retirement Accounts, Stock Bonus, Pension, Profit-Sharing, Annuity or Similar Qualified Plan (RSA 511:2(XIX)). Exempt from periodic payments up to $362.50 per week. If income and expenses are shared with another person with whom you live and the other person also receives income from such a retirement plan or arrangement, the exemption is up to $725.00 per week. Civil Service Retirement Benefits (5 U.S.C. 247 83466(a) Armed Forces Retirement Pay (10 U.S.C. 247 1440) Railroad Retirement Act Annuities and Pensions (45 U.S.C. 247 231m) Fireman222s Retirement Pay (RSA 102:23) Fireman222s Relief Payments (RSA 402:69) Foreign Services Retirement and Disability Payments (22 U.S.C. 247 4060(c)) Injury or Death Compensation Payments from War Risk Hazards (42 U.S.C. 247 1717) (With exception of monies paid as reimbursement for funeral expenses or as reimbursement with respect to payments of worker222s compensation or in the nature of worker222s compensation benefits.) Lighthouse Keepers Widow222s Benefits (33 U.S.C. 247775) Wages of Fisherman, Seaman and Apprentices (46 U.S.C. 247 11109) (With exception for an order of a court about the payment by a master or seaman of any part of the master222s or seaman222s wages for the support and maintenance of the spouse or minor children of the master or seaman, or both). Longshoremen222s and Harbor Worker222s Compensation Act Death and Disability Payments (33 U.S.C. 247 916) PLEASE NOTE: IF YOU HAVE INCOME FROM ANY OF THE SOURCES LISTED ABOVE, PLEASE BRING VERIFICATION (FOR EXAMPLE, YOUR AWARD LETTER) TO COURT WITH YOU. NHJB-4002-Se (07/01/2018) Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com