AFFIDAVIT OF FINANCIAL DISCLOSURE

Date: [MM/DD/YYYY]
Court: [COURT] County: [COUNTY] State: [STATE] Case Number: [#]

I, [AFFIANT NAME], the affiant, residing at [AFFIANT ADDRESS], being duly sworn, hereby swear under oath that the information stated in this Financial Affidavit and the attached documents, if any, is true and correct. I understand that willful misrepresentation of any of the information provided will subject me to sanctions and may result in criminal charges being filed against me.

1. INCOME. In support of the following income information, I have attached all necessary pay stubs, income tax returns, and W-2s and/or 1099 statements.

☐ Employed ☐ Self-Employed ☐ Unemployed
Employer: [EMPLOYER NAME] Hours worked per week: [#]
Address: [EMPLOYER ADDRESS]

Gross Income: $[DOLLAR AMOUNT] per [INCOME FREQUENCY]
Net Income: $[DOLLAR AMOUNT] per [INCOME FREQUENCY]

Other Income:

Source: [INCOME TYPE] $[DOLLAR AMOUNT] per [INCOME FREQUENCY]
Source: [INCOME TYPE] $[DOLLAR AMOUNT] per [INCOME FREQUENCY]

Number of other members in household: [#]
Income from other members: $[DOLLAR AMOUNT] per [INCOME FREQUENCY]

Any current child support orders? ☐ No. ☐ Yes in the amount of $[DOLLAR AMOUNT] to [RECIPIENT NAME]. If yes, attach copies of all support orders.

2. HEALTH INSURANCE. In support of the following insurance information, I have attached proof of health insurance coverage and cost.

Insurance Coverage: ☐ Employer ☐ Private ☐ Medicaid ☐ Medicare ☐ None
Coverage Includes: ☐ Medical  ☐ Dental ☐ Vision ☐ Prescription ☐ Other: [ADDTIONAL COVERAGE] Insurance Plan Name: [INSURANCE PLAN NAME] Policy #: [#]
Cost: $[DOLLAR AMOUNT] per [PAYMENT FREQUENCY] for Family Plan.
Cost: $[DOLLAR AMOUNT] per [PAYMENT FREQUENCY] for Individual Plan.

Child’s health insurance covered by: ☐ My Plan ☐ Other Parent’s Plan ☐ Medicaid ☐ Other: [CHILD INSURANCE PROVIDER]

3. CHILD CARE. Childcare Provider: [CHILDCARE PROVIDER] Number of Hours/Week: [#] for $[DOLLAR AMOUNT] per [PAYMENT FREQUENCY]

4. ASSETS. In support of the following asset information, I have attached all necessary documents proving the value of my assets.

Bank Accounts

Bank Name (Checking): [BANK NAME] Balance: $[DOLLAR AMOUNT]
Bank Name (Savings): [BANK NAME] Balance: $[DOLLAR AMOUNT]
Bank Name (Other): [BANK NAME] Type: [ACCOUNT TYPE] Balance: $[DOLLAR AMOUNT]

Vehicle(s)

Year: [YYYY] Make: [MAKE] Model: [MODEL] Value: $[DOLLAR AMOUNT]
Year: [YYYY] Make: [MAKE] Model: [MODEL] Value: $[DOLLAR AMOUNT]

Real Property

Type: [PROPERTY TYPE] Address: [PROPERTY ADDRESS] Market Value: $[DOLLAR AMOUNT] Mortgage: $[DOLLAR AMOUNT]
Type: [PROPERTY TYPE] Address: [PROPERTY ADDRESS] Market Value: $[DOLLAR AMOUNT] Mortgage: $[DOLLAR AMOUNT]

Other Assets

Details: [ASSET DETAILS] Market Value: $[DOLLAR AMOUNT]
Details: [ASSET DETAILS] Market Value: $[DOLLAR AMOUNT]

5. EXPENSES. The following is a list of my monthly expenses:

Type: [EXPENSE DETAILS] Cost: $[DOLLAR AMOUNT]
Type: [EXPENSE DETAILS] Cost: $[DOLLAR AMOUNT]
Type: [EXPENSE DETAILS] Cost: $[DOLLAR AMOUNT]
Type: [EXPENSE DETAILS] Cost: $[DOLLAR AMOUNT]

6. LOANS AND DEBTS. In support of the following debt information, I have attached all necessary documents related to my debts and loans.

Debt/Loan Details: [PROPERTY TYPE] Balance: $[DOLLAR AMOUNT] Payment: $[DOLLAR AMOUNT] ☐ Weekly ☐ Monthly
Debt/Loan Details: [PROPERTY TYPE] Balance: $[DOLLAR AMOUNT] Payment: $[DOLLAR AMOUNT] ☐ Weekly ☐ Monthly
Debt/Loan Details: [PROPERTY TYPE] Balance: $[DOLLAR AMOUNT] Payment: $[DOLLAR AMOUNT] ☐ Weekly ☐ Monthly

Under penalty of perjury, I hereby declare and affirm that the above-mentioned information is, to the best of my knowledge, true and correct.

Affiant Signature: ______________________________ Date: _______________

NOTARY ACKNOWLEDGMENT

A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.

State of [STATE]
County of [COUNTY]

The foregoing instrument was acknowledged before me, [NOTARY PUBLIC NAME], on [MM/DD/YYYY], by the undersigned, [AFFIANT NAME], who is personally known to me or satisfactorily proven to me to be the person whose name is subscribed to the within instrument.

WITNESS my hand and official seal.

Signature: ________________________

(Seal)