Affidavit Of Assets And Liabilities Page 2
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1
2Case Name:
Case Number:
AFFIDAVIT OF ASSETS & LIABILITIES
13. Please state your monthly household expenses:
Rent/Mortgage
$
Clothing
$
Property Taxes
$
Transportation
$
(including gas, maintenance, insurance repairs)
Heat
$
Food
$
Other (specify)
Utilities
$
Medical/Dental
$
Insurance
$
Total
$
0.00
14. List any real estate you own, its market value and the amount you owe:
15. List any vehicles you own (car, truck, boat, motorcycle, snowmobile, RV), their market value and
the amount you owe:
16. List income tax paid last year:
17. List income tax refund received last year:
18. Other than monthly household expenses, list any bills you owe, amount owed, to whom, and
monthly payment:
19. List which of your bills are court-ordered payments (i.e. alimony, judgment in a law suit, etc.):
20. Other than those previously mentioned, list anyone to whom you owe money, amount and when
it is due:
21. If anyone owes you money, state name, address, amount due, and when due:
22. List any property you have transferred within the last three years, to whom and for what price:
23. List any other assets or expenses not previously mentioned:
I swear the foregoing information is true and correct to the best of my knowledge under penalties of
law.
Date
Signature
Top of 1st Page
NHJB-2328-D (12/07/2006)
Page 2 of 2
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