IN DISTRICT COURT, COUNTY, STATE OF NORTH DAKOTA , Plaintiff, vs. , Defendant. STATE OF NORTH DAKOTA COUNTY OF I, A. } } } } } } } } } } } FINANCIAL AFFIDAVIT IN SUPPORT OF PETITION FOR WAIVER OF FEES DATE: Civil No. ss. , being first duly sworn state as follows: ASSETS I have cash on hand: $ I have on deposit in financial institutions: $ I have stocks and bonds in the amount of: $ Total Other assets and approximate value are (list): ITEM VALUE IN POSSESSION OF $ $ $ $ $ Total (Attach additional schedules as needed) Total Assets $ American LegalNet, Inc. www.FormsWorkFlow.com B. LIABILITIES. CREDITORS UNPAID MONTHLY BALANCE PAYMENT $ $ $ $ $ $ $ $ $ $ $ $ TOTAL (Attach additional schedules as needed) Total Liabilities: C. INCOME. My monthly income, and that of my spouse, is as follows: AFFIANT SPOUSE GROSS INCOME $ $ DEDUCTIONS $ $ FEDERAL TAX $ $ FICA $ $ MEDICARE $ $ STATE TAX $ $ HEALTH INSURANCE $ $ RETIREMENT $ $ SAVINGS $ $ OTHER $ $ TOTAL DEDUCTIONS $ $ NET INCOME $ $ My pay period is every __________________________. My spouse’s pay period is every __________________________. American LegalNet, Inc. www.FormsWorkFlow.com D. EXPENSES. My current monthly expenses to support myself and my child(ren) are as follows: HOUSE/RENT PAYMENT $ GAS/ELECTRICITY $ HOMEOWNER’S/RENT INSURANCE $ WATER $ TELEPHONE $ CABLE/SATELLITE TELEVISION $ FOOD AND HOUSEHOLD ITEMS $ CLOTHING $ LAUNDRY $ LIFE INSURANCE $ AUTOMOBILE INSURANCE $ MEDICAL INSURANCE $ TRANSPORTATION $ CHILD CARE $ SCHOOL EXPENSES $ UNREIMBURSED MEDICAL, DENTAL, OPTICAL $ NEWSPAPER AND MAGAZINES $ DONATIONS $ ENTERTAINMENT $ MISCELLANEOUS $ TOTAL $ American LegalNet, Inc. www.FormsWorkFlow.com DATED: My Signature (Sign only in presence of notary public or Clerk of Court) Street Address City/State/Zip , 20______. Subscribed and sworn to before me on Notary Public or Clerk of Court American LegalNet, Inc. www.FormsWorkFlow.com