APPENDIX B. FINANCIAL STATEMENT AND AFFIDAVIT

Effective Date: 3/1/2000

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
PAYMENT
MONTHLY
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 myselfand 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
Effective Date Obsolete Date
03/01/2000 View
03/01/2000 03/01/2000 View