Fine Payment Financial Affidavit
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THE STATE OF NEW HAMPSHIRE
JUDICIAL BRANCH
Court Name:
Case Name:
Case Number:
(if known)
FINE PAYMENT FINANCIAL AFFIDAVIT
Name:
Address:
Telephone #: H:
W:
C:
Date of Birth:
Age:
Marital Status:
Single
Married
Divorced
Separated
List all dependents you currently support, including your spouse, or any other persons who reside with
you (name, relationship, date of birth, and address if different from your own).
A.
C.
B.
D.
1. Available Money
SELF (A)
SPOUSE/ADULT IN
HOUSEHOLD (B)
a. Cash on hand
$
$
b. Checking account
$
$
Bank name:
c. Savings account
$
$
Bank name:
d. Credit cards (list the balance):
VISA:
$ (
) $ (
)
Mastercard:
$ (
) $ (
)
Other:
$ (
) $ (
)
Available credit on credit cards
$
$
e. Stocks, Bonds, Trusts, CDs, Other
$
$
f. Christmas Club
$
$
g. Other
$
$
TOTAL (1)
$
$
0.00
0.00
(1A)
(1B)
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NHJB-2534-D (06/04/2008)
Page 1 of 5
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