Family Law Financial Affidavit (Short Form) Page 5

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SECTION II. AVERAGE MONTHLY EXPENSES
Proposed/Estimated Expenses. If this is a dissolution of marriage case and your expenses as listed
below do not reflect what you actually pay currently, you should write “estimate” next to each amount
that is estimated.
A. HOUSEHOLD:
Mortgage or rent
$ _______
E. OTHER EXPENSES NOT LISTED ABOVE
Property taxes
$_______
Clothing
$ _______
Utilities
$_______
Medical/Dental (uninsured)
$_______
Telephone
$ _______
Grooming
$ _______
Food
$ _______
Entertainment
$_______
Meals outside home
$_______
Gifts
$_______
Maintenance/Repairs
$ _______
Religious organizations
$_______
Other: __________
$_______
Miscellaneous
$_______
Other: ______________
$ _______
B. AUTOMOBILE
____________________
$_______
Gasoline
$ _______
____________________
$_______
Repairs
$_______
____________________
$_______
Insurance
$_______
____________________
$_______
____________________
$_______
C. CHILD(REN)’S EXPENSES
Day care
$ _______
Lunch money
$_______
F. PAYMENTS TO CREDITORS
Clothing
$ _______
CREDITOR:
MONTHLY
Grooming
$_______
PAYMENT
Gifts for holidays
$ _______
____________________
$_______
Medical/Dental (uninsured)
$ _______
____________________
$_______
____________________
$_______
Other: ______________
$ _______
____________________
$_______
____________________
$_______
D. INSURANCE
____________________
$_______
Medical/Dental (if not listed on
____________________
$_______
lines 23 or 45)
$ _______
____________________
$_______
Child(ren)’s medical/dental
$ _______
____________________
$_______
Life
$ _______
____________________
$_______
Other:
$ _______
____________________
$_______
Florida Family Law Rules of Procedure Form 12.902(b), Family Law Financial Affidavit (Short Form) (01/15)

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