N.D.R.Ct.
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, NDROC,
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
1. ______________________ ___________ _______________
2. ______________________ ___________ _______________
3. ______________________ ___________ _______________
4. ______________________ ___________ _______________
5. ______________________ ___________ _______________
6. ______________________ ___________ _______________
(Attach additional schedules as needed)
B. LIABILITIES.
CREDITORS UNPAID MONTHLY PAYMENT
BALANCE
1. ______________________ ___________ _______________
2. ______________________ ___________ _______________
3. ______________________ ___________ _______________
4. ______________________ ___________ _______________
5. ______________________ ___________ _______________
6. ______________________ ___________ _______________
(Attach additional schedules as needed)
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 _______ _______
Net Income _______ _______
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:
House/rent Payment ______________
Gas/electricity ... ______________
Homeowner's/Rent Insurance .. ______________
Water ... ______________
Telephone .... ______________
Cable 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 ... ______________
Dated this _________ day of _______________, 199_.
_________________________
(Affiant)
Subscribed and sworn to before me this _______ day of ___________, 199_.
_________________________
Notary Public