Form Ujs-304b Financial Affidavit (Page 3 of 4) in pdf

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If you provide medical or dental insurance for your child(ren), please complete the following:

Name of the Health and/or Dental Insurance Company ______________________________________

Total monthly cost for the employee only: $_____________________________

Total monthly cost for the employee and child(ren): $__________________________

Persons covered under the policy of insurance: ___________________________________________________.

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Do you incur child care costs as result of employment, job search or training or education necessary to obtain a job or

enhance earning potential? ________________________

If so, please complete the following:

Name and address of child care provider: __________________________________________________________.

The name(s) of the child(ren) for whom child care is provided: __________________________________________.

How many hours per week is child care being provided? _______________________________________________.

Cost of Child Care: Monthly: $_______________ Weekly: $____________ Hourly: $______________

List the costs, per month, of the child care expenses incurred for the past six months: __________________________

_______________________________________________________________________________________________

Do you receive any state assistance for child care? _________________ If so, how much? ____________________

Do you claim the Federal Child Care Tax Credit? __________________

Enter the amount of Social Security or Veteran’s Benefits provided to a child(ren) of the parties due to your

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retirement, disability or other eligibility: $_____________________

Which parent receives the payment for the child? ______________________

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The following amounts accurately represent my assets and liability:

ASSETS (things we own or are 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, CD’s, money market, stock options, etc.)…..

$_____________

d. RETIREMENT ACCOUNT (account balance)……………………………………………….

$_____________

e. REAL ESTATE (house, land, tribal lease land, rental property, etc.)…………………………

$_____________

f. AUTOMOBILE(S) make, model, year:

________________________________________________________________________

$_____________

________________________________________________________________________

$_____________

g. RECREATIONAL VEHICLES (boats, campers, ATV’s, etc)……………………………….

$_____________

h. HOUSEHOLD GOODS (furniture, appliances, TV, stereo, etc.)……………………………..

$_____________

i. SPORTING EQUIPMENT (hunting/fishing, camping, boating, etc.)………………………..

$_____________

j. JEWLREY……………………………………………………………………………………..

$_____________

k. TOOLS, SHOP EQUIPMENT………………………………………………………………..

$_____________

l. VALUE OF BUSINESS ………………………………………………………………………

$_____________

m. OTHER PERSONAL PROPERTY (tools, sports equipment, etc.)………………………..…

$_____________

n. ANY OTHER ASSETS (anything else I could sell or borrow money on)…………………..

$_____________

TOTAL VALUE OF ASSETS………….

$_____________

LIABILITIES (money that we owe)

a. Our regular monthly expenses are: (housing, utilities, food, insurance, etc.)……….….$_____________

b. DEBTS (vehicle loans, mortgages, credit cards, student loans, medical bills, personal loans, etc.):

I owe_______________________________ this amount……………….$_____________

I owe _______________________________this amount……………….$_____________

I owe_______________________________ this amount……………….$_____________

I owe _______________________________this amount……………….$_____________

I owe_______________________________ this amount……………….$_____________

I owe _______________________________this amount……………….$_____________

Page 3 of 4

Form UJS-304B

Rev. 01/2015

Form Ujs-304b Financial Affidavit Page 3

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