Affidavit Of Assets And Liabilities
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THE STATE OF NEW HAMPSHIRE
JUDICIAL BRANCH
Court Name:
Case Name:
Case Number:
(if known)
AFFIDAVIT OF ASSETS AND LIABILITIES
1.
Name:
DOB:
2.
Where do you live?
3.
Marital Status:
Single
Married
Separated
Widowed
4.
List the names, ages, relationships of dependents you support:
5.
If you are presently employed, state where and for how long:
Full-Time
Part-Time
6.
If unemployed, state last date of employment:
7.
When do you anticipate new employment?
8.
If your spouse is presently employed, state where and for how long?
Full-Time
Part-Time
9.
If spouse unemployed, state last date of employment:
10. List other employed household members and their weekly income:
11. Please state weekly take-home amount
Yours
Spouse’s
Salary/Wages
$
$
Pension/Trust Benefits
$
$
Unemployment Compensation
$
$
Social Security
$
$
Investment income
$
$
Alimony
$
$
Child Support
$
$
Welfare Payments
$
$
Other
$
$
Total
$
$
0.00
0.00
12. What money is presently available to you?
Cash on hand ..................................................................................... $
Checking account ............................................................................... $
Savings account ................................................................................. $
Stocks/Bonds/IRA/Pension ................................................................. $
Total
$
0.00
NHJB-2328-D (12/07/2006)
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