NHJB-3037-SUP (08/06/2018) Page 1 of 3 THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH htt p ://www.courts.state.nh.us Court Name: Case Name: Case Number: AFFIDAVIT OF ASSETS AND LIABILITIES v. Plaintiff Defendant 1. Name: DOB: 2. Where do you live? 3. What is your marital status? 4. List the names, ages, and relationships of dependents you support: 5. If you are presently employed, state where, whether full time or part time and for how long: Employer name Full/part time Length of employment 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 SPOUSE222S Salary/Wages $ $ Pension/Trust Benefits $ $ Unemployment Comp. $ $ Social Security $ $ Investment Income $ $ Alimony $ $ Child Support $ $ Welfare Payments $ $ Other $ $ TOTAL $ $ American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: AFFIDAVIT OF ASSETS AND LIABILITIES NHJB-3037-SUP (08/06/2018) Page 2 of 3 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 inmate222s account for the last three months: $ 14. Please state your monthly household expenses: Rent/Mortgage $ Clothing $ Property Taxes $ Transportation $ Heat $ (including gas, maintenance, insurance, repairs) Food $ Other $ Utilities $ (specify type of expense) 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, 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: American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: AFFIDAVIT OF ASSETS AND LIABILITIES NHJB-3037-SUP (08/06/2018) Page 3 of 3 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 SHEET OF 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. /s/ 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. /s/ Date Signature Subscribed and sworn by appellant, before me. Date Notary Public American LegalNet, Inc. www.FormsWorkFlow.com