Financial Affidavit - The State Of New Hampshire Judicial Branch
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THE STATE OF NEW HAMPSHIRE
JUDICIAL BRANCH
Court Name:
Case Name:
Case Number:
(if known)
FINANCIAL AFFIDAVIT
1. General Information
4. Monthly Income - Miscellaneous
Name
AFDC, TANF, and Food Stamps
$
Street Address
Other Public Assistance
$
Town/City, State, Zip
Children's Income
$
Mailing Address, if different
Child Support
$
Date of Birth
5. Monthly Income Before Taxes
Social Security Number
Base Pay from Salary, Wages
$
Highest Grade or Degree Completed
Overtime and Shift Differential
$
Date of Marriage
Commissions, Tips, Bonuses
$
Date of Separation or Divorce
Part-time Employment
$
Self-employment
$
2. Children born to, or adopted by, the Parties (Full Name, DOB, and SSN)
Unemployment and Veteran's Benefits
$
Disability, Workers' Compensation
$
Pension and Retirement Benefits
$
Social Security Benefits (SSA)
$
Interest and Dividends
$
2a. Number of people currently living in household including self:
Trust and Other Investment Income
$
3. Employment Information
Rental Income and Business Profits
$
Name, Address, and Phone Number of Employer
All other sources
$
Total Section 5 Monthly Income
$
0.00
6. Monthly Expenses
Date and Place of Last Employment
Court Ordered Support for Others
$
State Income Taxes
$
Mandatory Pension
$
Job Skills
Health Insurance for Parties' Children
$
Day Care for Parties' Children
$
Total Section 6 Monthly Expenses
$
0.00
7. Assets
Fair Market Value
Related Debt
Additional Information
Homestead
$
$
Other Real Estate
$
$
Primary Motor Vehicle
$
$
Other Motor Vehicles
$
$
Furniture and Appliances
$
$
Checking Accounts
$
$
Investments
$
$
Life Insurance
$
$
Business Interests
$
$
Pensions
$
$
Retirement Accounts
$
$
NHJB-2065-FS (03/25/2013)
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