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 |