STATE OF NEW HAMPSHIRE SUPREME COURT Docket No. v. Plaintiff Defendant AFFIDAVIT OF ASSETS AND LIABILITIES 1. Name: DOB: 2. Where do you live: Single 3. Marital Status: Married Divorced Separated Widowed 4. List the names, ages, and relationships of dependents you support: Full Time 5. If you are presently employed, state where and for how long: Part Time 6. If unemployed, state last date of employment: 7. When do you anticipate new employment: 8. If your spouse is presently employed, state where and for how long: 9. If your spouse is unemployed, state last date of employment: 10. List other employed household members and their weekly income: 11. Please state weekly take-home amount: YOURS SPOUSE’S Salary/Wages $ $ Pension/Trust Benefits $ $ Unemployment Comp. $ $ Social Security $ $ Investment Income $ $ Alimony $ $ Child Support $ $ Welfare Payments $ $ Other $ $ TOTAL $ $ 12. What money is presently available to you: Cash on hand $ $ Checking Account Name of Bank Savings Account $ Name of Bank Stocks/Bonds/Ira/Pension $ Identify TOTAL $ 13. (If inmate) State amount deposited in inmate’s account for the last three months: $ American LegalNet, Inc. www.USCourtForms.com 14. Please state your monthly household expenses: Rent/Mortgage $ Property Taxes $ Heat $ Utilities $ Medical/Dental $ Insurance $ Transportation $ $ Food Clothing $ (including gas, maintenance, insurance, repairs) Other $ (specify type of expense): TOTAL $ 15. List any real estate you own, its market value and the amount you owe: 16. List any vehicles you own (car, truck, 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 payments: 20. Other than those previously mentioned, list anyone to whom you owe money, amount and when it is due: 21. List court-ordered bills (i.e., alimony, judgment in law suit, etc.): 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: IF YOU NEED ADDITIONAL SPACE TO ANSWER ANY QUESTION ABOVE, ATTACH A SHEETOF PAPER TO THIS FORM AND PROVIDE THE ADDITIONAL INFORMATION ON IT. I swear the foregoing information and any information provided by me on any attached sheets is true and correct to the best of my knowledge under penalties of law. Date Signature (The following section must be completed only by inmates.) I swear under oath that this civil claim has not been previously brought against the same parties or from the same operative facts in any state or federal court. I further swear that the foregoing information and any information provided by me on any attached sheets is true and correct to the best of my knowledge under penalties of law. Date Signature Subscribed and sworn by appellant, before me. Date Notary Public American LegalNet, Inc. www.USCourtForms.com