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 |
|