Financial Affidavit Form - South Dakota Page 2
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3STATE OF SOUTH DAKOTA)
IN CIRCUIT COURT
:SS
COUNTY OF______________)
___________ JUDICIAL CIRCUIT
_____________________,
DIV _____
Plaintiff,
FINANCIAL AFFIDAVIT
vs.
_____________________,
Defendant.
I, ________________________________, hereby swear on oath and under penalty of law that the following is true.
(Name of party completing affidavit)
(1)
My address is ______________________________________________________
(2)
My telephone number is (
) _______________________________________
(3)
I am (check one) _____ EMPLOYED _____ UNEMPLOYED _____ SELF-EMPLOYED
(4)
(If employed) my weekly take home pay is: $_____________________________.
(5)
Retirement, disability, or insurance benefits: $________________ per ______________.
(6)
My total income before deductions for year _________ was $______________________.
(7)
My total income before deductions for year _________ was $______________________.
(8)
Including myself, I have the following number of dependants: _____________________.
(10)
The following amounts accurately represent my assets and liability:
I.
ASSETS (things I own or am buying)
a. CASH (on hand or in banks) ……………………………………………………………..$_____________
b. ACCOUNTS and NOTES RECEIVABLE (IOU’s and other money payable to me)…...$_____________
c. INVESTMENTS (stocks, bonds, savings bond, etc.)…………………………………….$_____________
d. REAL ESTATE (house, land, tribal lease land, rental property, etc.)…………………….$_____________
e. AUTOMOBILE(S) make, model, year:
________________________________________________________________________ $_____________
f. HOUSEHOLD GOODS (furniture, appliances, TV, stereo, etc.)…………………………$_____________
g. OTHER PERSONAL PROPERTY (tools, sports equipment, etc.)………………………$_____________
h. ANY OTHER ASSETS (anything else I could sell or borrow money on)……………….$_____________
TOTAL ASSETS………….$_____________
II.
LIABILITIES (money that I owe)
a. My regular monthly expenses are: (housing, utilities, food, etc.)…………………….….$_____________
b. DEBTS:
I owe_______________________________ this amount……………….$_____________
I owe_______________________________ this amount……………….$_____________
I owe_______________________________ this amount……………….$_____________
TOTAL LIABILITIES …..$_____________
Form UJS-304 Rev. 11/2010
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