APPENDIX B. FINANCIAL STATEMENT AND AFFIDAVIT
STATE OF NORTH DAKOTA IN DISTRICT COURT
COUNTY OF _____________ _________ JUDICIAL DISTRICT
Civil No.
A.B., Plaintiff ) RULE 8.2, N.D.R.Ct.,
vs. ) FINANCIAL STATEMENT
C.D., Defendant ) AND AFFIDAVIT
Your affiant, being first duly sworn, states as follows:
A. ASSETS.
1. I have cash on hand:
$_________
2. I have on deposit in financial institutions:
$_________
3. I have stocks and bonds in the amount of:
$_________
4. Other assets and approximate value are (list):
ITEM VALUE IN POSSESSION OF
5. ______________________ ___________ _______________
6. ______________________ ___________ _______________
7. ______________________ ___________ _______________
8. ______________________ ___________ _______________
9. ______________________ ___________ _______________
10. ______________________ ___________ _______________
(Attach additional schedules as needed)
11. Total Assets _________________________________________
B. LIABILITIES.
CREDITORS UNPAID
MONTHLY PAYMENT
BALANCE
12. ___________________ ___________ _______________
13. ___________________ ___________ _______________
14. ___________________ ___________ _______________
15. ___________________ ___________ _______________
16. ___________________ ___________ _______________
17. ___________________ ___________ _______________
(Attach additional schedules as needed)
18. Total Liabilities ______________________________________
C. INCOME. My monthly income, and that of my spouse, is as follows:
AFFIANT SPOUSE
19. Gross Income _______ _______
20. Deductions
21. Federal Tax _______ _______
22. FICA _______ _______
23. Medicare _______ _______
24. State Tax _______ _______
25. Health Insurance _______ _______
26. Retirement _______ _______
27. Savings _______ _______
28. Other _______ _______
29. Total Deductions _____________________________
30. Net Income _______ _______
31. My pay period is every _________________. My spouses's pay period is every ______________.
D. EXPENSES. My current monthly expenses to support myself and child(ren) are as follows:
32. House/Rent Payment...................... ______________
33. Gas/Electricity................................ ______________
34. Homeowner's/Rent Insurance......... ______________
35. Water.............................. ______________
36. Telephone.......................... ______________
37. Cable Television................... ______________
38. Food and Household Items........... ______________
39. Clothing........................... ______________
40. Laundry............................ ______________
41. Life Insurance.................... ______________
42. Automobile Insurance............... ______________
43. Medical Insurance.................. ______________
44. Transportation..................... ______________
45. Child Care......................... ______________
46. School Expenses.................... ______________
47. Unreimbursed Medical, Dental,
Optical............................ ______________
48. Newspaper and Magazines............ ______________
49. Donations.......................... ______________
50.Entertainment....................... ______________
51. Miscellaneous...................... ______________
52. TOTAL.............................. ______________
Dated (Month) (Day), (Year).
_________________________
(Affiant)
Subscribed and sworn to before me on (Month) (Day), (Year).
_________________________
Notary Public