APPENDIX B. FINANCIAL STATEMENT AND AFFIDAVIT
Effective Date: 3/1/2000
Obsolete Date: 3/1/2000
APPENDIX B. FINANCIAL STATEMENT AND AFFIDAVIT
__________, being duly sworn, says that affiant is the________ (Plaintiff or Defendant) herein, and has read this financial statement and knows the contents thereof and that the same is true.
1. My monthly gross income from all sources is $_______ 2. My spouse's monthly gross income from all sources is $_______ 3. My monthly take-home pay therefrom is $_______ 4. I have cash on hand $_______ 5. I have on deposit in banks $_______ 6. I have stocks and bonds in the amount of $_______ 7. Other assets and approximate value are (list) $_______ 8. The debts of myself and my spouse are: $_______ Creditors Unpaid Monthly Balance Payments __________________________________ $_______ $_______ __________________________________ $_______ $_______ (Attach additional schedules as needed) Total............................ $_______ $_______ 9. My necessary monthly expenses to support myself (and child or children) are as follows: Rent or House Payment$_______ Life Insurance $_______ Water $_______ Fire Insurance $_______ Telephone $_______ Transportation $_______ Food $_______ Baby Sitter $_______ Clothing $_______ Drugs $_______ Laundry $_______ Medical $_______ Other (list) $_______ (Attach additional schedules as needed) Total ....................................... $_______ Subscribed and sworn to before me this _______ day of _______, 19__. ___________________________ Notary Public My commission expires: