Financial Affidavit (Page 3 of 4) in pdf

NET MONTHLY INCOME (SUBTRACT TOTAL DEDUCTIONS FROM GROSS MONTHLY

INCOME): $__________________

(19)

My total gross income before deductions for the previous year was $______________________.

(20)

My total gross income before deductions for two years ago was $______________________.

(21)

Including myself, I have the following number of dependents: _____________________.

(22)

Do you have health insurance available for your spouse through your employer? _________________

(23)

If you provide medical or dental insurance for your spouse, please complete the following:

Name of the Health and/or Dental Insurance Company ______________________________________

Total monthly cost for the employee only: $_____________________________

Total monthly cost for the employee and spouse: $__________________________

Persons covered under the policy of insurance: ___________________________________________________.

(24)

The following amounts accurately represent my assets and liability:

ASSETS (things we own or are buying)

a. CASH (on hand or in banks) …………………………………………………………………..

$_____________

b. ACCOUNTS and NOTES RECEIVABLE (IOU’s and other money payable to me)………..

$_____________

c. INVESTMENTS(stocks, bonds, savings bond, CD’s, money market, stock options, etc.)…..

$_____________

d. RETIREMENT ACCOUNT (account balance)……………………………………………….

$_____________

e. REAL ESTATE (house, land, tribal lease land, rental property, etc.)…………………………

$_____________

f. AUTOMOBILE(S) make, model, year:

________________________________________________________________________

$_____________

________________________________________________________________________

$_____________

g. RECREATIONAL VEHICLES (boats, campers, ATV’s, etc)……………………………….

$_____________

h. HOUSEHOLD GOODS (furniture, appliances, TV, stereo, etc.)……………………………..

$_____________

i. SPORTING EQUIPMENT (hunting/fishing, camping, boating, etc.)………………………..

$_____________

j. JEWELRY……………………………………………………………………………………..

$_____________

k. TOOLS, SHOP EQUIPMENT………………………………………………………………..

$_____________

l. VALUE OF BUSINESS ………………………………………………………………………

$_____________

m. OTHER PERSONAL PROPERTY (tools, sports equipment, etc.)………………………..…

$_____________

n. ANY OTHER ASSETS (anything else I could sell or borrow money on)…………………..

$_____________

TOTAL VALUE OF ASSETS………….

$_____________

LIABILITIES (money that we owe)

a. Our regular monthly expenses are: (housing, utilities, food, insurance, etc.)……….….$_____________

b. DEBTS (vehicle loans, mortgages, credit cards, student loans, medical bills, personal loans, etc.):

I owe_______________________________ this amount……………….$_____________

I owe _______________________________this amount……………….$_____________

I owe_______________________________ this amount……………….$_____________

I owe _______________________________this amount……………….$_____________

I owe_______________________________ this amount……………….$_____________

I owe _______________________________this amount……………….$_____________

TOTAL LIABILITIES …..$_____________

Form UJS-304A

Rev. 11/2014

Financial Affidavit Page 3

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