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
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