CASE NUMBER ____________________________ To be assigned by Court JUDICIAL BRANCH - SUPERIOR COURT IN THE MATTER OF: FINANCIAL AFFIDAVIT OF 1. General Information Street Address _______________________________________________ ____________________________________________________________ Town/City, State, Zip __________________________________________ Mailing Address, if different ____________________________________ Date of Birth ________________________________________________ Social Security Number _______________________________________ Highest Grade or Degree Completed ____________________________ Date of Marriage _____________________________________________ Date of Separation or Divorce __________________________________ 2. Children of the Parties (Full Name, DOB, and SSN) ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ 3. Employment Information Name, Address, and Phone Number of Employer __________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Date and Place of Last Employment _____________________________ ____________________________________________________________ ____________________________________________________________ Job Skills ___________________________________________________ ____________________________________________________________ 7. Assets Homestead Other Real Estate Primary Motor Vehicle Other Motor Vehicles Furniture and Appliances Checking Accounts Investments SC-FA-WEB03 Fair Market Value 4. Monthly Income - Miscellaneous $ ______________ $ ______________ $ ______________ $ ______________ AFDC, TANF, and Food Stamps Other Public Assistance Children's Income Child Support 5. Monthly Income Before Taxes Base Pay from Salary, Wages Overtime and Shift Differential Commissions, Tips, Bonuses Part-time Employment Self-employment Unemployment and Veteran's Benefits Disability, Workers' Compensation Pension and Retirement Benefits Social Security Benefits (SSA) Interest and Dividends Trust and Other Investment Income Rental Income and Business Profits All other sources ___________________________________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ Total Section 5 Monthly Income 6. Monthly Expenses Court Ordered Support for Others State Income Taxes Mandatory Pension Health Insurance for Parties' Children Day Care for Parties' Children Related Debt American LegalNet, Inc. www.USCourtForms.com $ _____________ $ _____________ $ _____________ $ _____________ $ _____________ Additional Information Financial Affidavit Pg. 1 of 3 Case Number: _______________________ Life Insurance Business Interests Pensions Retirement Accounts 8. Additional Assets - If you have an interest in any property which is held solely by or jointly with any other person or entity, and which has not already been disclosed, or if you are owed money from any source, please explain __________ 9. Tax Return Information 11. Debts Year of last return filed ___________________________________ Single or joint return _____________________________________ My Total W-2s and 1099s = $_____________________ [ ] If Self-employed, check here and attach copy of most recent IRS Schedule C. Who is debt owed to? Who owes debt? Balance _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ 10. Insurance Life Company _______________________________________________ Type and Face Amount ___________________________________ Beneficiaries ____________________________________________ Health _________________________________________________ Company _______________________________________________ Type ___________________________________________________ Description of Coverage __________________________________ ________________________________________________________ Dental Company _______________________________________________ Description of Coverage __________________________________ ________________________________________________________ 12. Retirement Plans Plan or Account Name _____________________________________ Type ____________________________________________________ Most Recent Value ________________________________________ Value at Filing ____________________________________________ If Defined Benefit, status of vesting and description of Benefit _________________________________________________________ _________________________________________________________ 13. Attachments: [ ] Pay Stub [ ] Monthly Expenses [ ] Schedule C [ ] Other (describe) ____________________ [ ] Check here if Monthly Expenses form waived. 14. Additional Information I swear (affirm) that: A. To the best of my knowledge and belief, I have fully disclosed all income and all assets having any substantial value; and B. I have reasonably estimated the fair market value of each asset; and C. I understand that I have a duty to update the information provided in this financial affidavit for each court hearing; and D. I understand that if a support order is issued in this case obligating me to pay support, it shall be my responsibility to immediately provide the Court with any change of address in writing. If I fail to do so, I may be held in default, found in contempt of court and a warrant may be issued for my arrest. (See USO Standing Order SO-4C.) Date Signature State of New Hampshire County of ______________________ The person signing this financial affidavit appeared and signed this before me and took oath that the statements set forth in this Financial Affidavit, together with any attachments listed in section 13 above, are true to the best of his or her knowledge and belief. Date Notary Public / Justice of the Peace I certify that a copy of this financial affidavit (and any attachments) was this day mailed / given to (lawyer for other side, if any) (other side, if no lawyer) (OCSE, if State is a party): Date SC-FA-WEB03 Signature American LegalNet, Inc. www.USCourtForms.com Financial Affidavit Pg. 2 of 3 Monthly Expenses Case Number: NOTE: Round all numbers to the nearest dollar. To convert weekly expenses to monthly, multiply by 4.33. 6. General and Personal 1. Housing Rent Mortgage Payment Property Tax Condo Fee Home Maintenance Snow Removal and Lawn Care ________________________________________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ 2. Utilities Heating Oil Wood and Coal Propane and Natural Gas Telephone Electricity Cable Television Water and Sewer Trash Collection ________________________________________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ 3. Insurance Homeowner Renter Vehicle Health Dental Life Disability $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ Groceries Meals Eaten Out Tobacco/Alcohol Products Clothing and Shoes Hair Care Toiletries and Cosmetics Pet Food and Care Church and Charities Laundry and Dry Cleaning Gifts Newspapers and Magazines Education (personal) Dues and Memberships Vacations Entertainment and Recreation Visitation Expenses ___________________________________ $______________ $______________ $______________ $______________ $______________ $______________ $______________ $______________ $______________ $______________ $______________ $______________ $______________ $______________ $______________ $______________ $______________ 7. Children's Expenses and Activities Children's Clothing and Shoes Diapers Day Care School Supplies School Lunches Tuition and Lessons Sports and Camp ___________________________________ $______________ $______________ $______________ $______________ $______________ $______________ $______________ $______________ 8. Financial 4. Uninsured Health Care Medical Dental Orthodontics Eye Care/Glasses/Contacts Prescription Drugs Therapy and Counseling ________________________________________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ Federal Income Tax Social Security and Medicare Loan Payments Other Debts Savings 401(k) IRA Other Retirement Plans ____________________________________ ____________________________________ $______________ $______________ $______________ $______________ $______________ $______________ $______________ $______________ $______________ $______________ 5. Transportation Primary Vehicle Payment Other Vehicle Payments Vehicle Maintenance Gas and Oil Registration and Tax ________________________________________ ________________________________________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ 9. Other Expenses $______________ $______________ $______________ $______________ $______________ $______________ TOTAL MONTHLY EXPENSES SC-FA-WEB03 ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ $______________ American LegalNet, Inc. www.USCourtForms.com Financial Affidavit Pg. 3 of 3