Financial Affidavit -State Of Connecticut Superior Court Page 2
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1
2ADDRESS
VALUE (Est )
MORTGAGE
EQUITY
Home
$
$
$
ADDRESS
VALUE (Est )
MORTGAGE
EQUITY
A. Real
Other:
$
$
$
Estate
ADDRESS
VALUE (Est )
MORTGAGE
EQUITY
Other:
$
$
$
YEAR
MAKE
MODEL
VALUE
LOAN BALANCE
EQUITY
Car 1:
$
$
$
B. Motor
Vehicles
YEAR
MAKE
MODEL
VALUE
LOAN BALANCE
EQUITY
Car 2:
$
$
$
DESCRIBE AND STATE VALUE OF EACH ITEM
TOTAL
C. Other
VALUE
Personal
Property
$
BANK NAME, TYPE OF ACCOUNT, AND AMOUNT
TOTAL
BANK ACCOUNTS
D. Bank
Accounts
$
4.
NAME OF COMPANY, NUMBER OF SHARES, AND VALUE
ASSETS
E. Stocks,
TOTAL
Bonds
VALUE
Mutual
Funds
$
NAME OF INSURED
COMPANY
FACE AMOUNT
CASH VALUE
AMT. OF LOAN
TOTAL
$
$
$
F. Insurance
VALUE
(exclude
$
$
$
children)
$
$
$
$
NAME OF PLAN (Individual I.R.A., 401K, Keogh, etc ) AND APPROX. VALUE
TOTAL
G. Deferred
VALUE
Compen-
(less loans)
sation
Plans
$
TOTAL
H. All Other
VALUE
Assets
$
$
I. Total
E.
TOTAL CASH VALUE OF ALL ASSETS
NAME AND ADDRESS OF HEALTH OR DENTAL INSURANCE CARRIER (Do not include policy number)
5.
HEALTH
INSURANCE
NAME(S) OF PERSON(S) COVERED BY THE POLICY
SUMMARY
(Use the amounts shown in boxes A thru E of sections 1-4.)
TOTAL NET WEEKLY INCOME (A)
TOTAL CASH VALUE OF ASSETS (E)
$
$
TOTAL WEEKLY EXPENSES AND
TOTAL LIABILITIES
$
$
LIABILITIES (B + D)
(TOTAL BALANCE DUE ON DEBTS) (C)
CERTIFICATION
I certify that the foregoing statement is true and accurate to the best of my knowledge and belief.
SIGNED (Affiant)
DATE
SIGNED (Notary, Comm. of Superior Court, Assistant Clerk)
Subscribed and sworn
to before me on
JD-FM-6 Rev. 1-08 (Back)
RESET
PRINT
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