Form Pc-003 - Child Protection Financial Affidavit 2009 Page 2
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24. Do you expect to receive any payments such as retroactive government benefits, tax refunds, settlements, etc?
yes
no If yes, describe____________________________________________
5. Does anyone owe you money?
yes
no If yes, describe
ASSETS AND DEBTS
1. Assets (Give current values)
Real estate
Car/truck
Boat/rec. vehicles
Bank accounts
Pension
Securities
Any other item worth over $50______________________________________________________
2. Debts
Mortgage balance___________________
Monthly payment_____________
Loan balances_____________________
Monthly payments______________
Credit card debts___________________
Monthly payments_______________
DEPENDENTS
Children (give names and dates of birth)_______________________________________________
______________________________________________________________________
The children live with
me
other parent
other
some with me/some with others
I pay support of : __________
per___________
for ________________________
Total child support paid last year__________
; this year to date ______________
Do you have other dependents? If so, list:_______________________________________________
Does anyone provide you with support? (Spouse/partner/parent, etc.)
yes
no If yes, identify: ___
______________________________________________________________________________
CHILD RELATED COSTS
Cost of health insurance for children ______________
(To determine this amount, deduct the cost of insurance for yourself from the cost for the family.)
Weekly child care costs so you can work or train to work____________________
Do any of your children have regular recurring medical expenses? (for example, asthma medication)
yes
no If yes, give details and amount _______________________________________
______________________________________________________________________________
OTHER
Describe any other facts you believe are important to understand your financial situation.
______________________________________________________________________
______________________________________________________________________
ON MY OATH, AND TO THE BEST OF MY KNOWLEDGE AND BELIEF, THIS AFFIDAVIT IS TRUE AND
INCLUDES ALL OF MY INCOME, ASSETS AND DEBTS.
Date:
________________________
Signature
Subscribed and sworn to before me:
Date:
________________________
(Attorney)(Notary)(Deputy Clerk)
Based on review of the parent’s financial circumstances, including an interview with the parent, I make the following recommendation:
Eligible
Not eligible
Partially eligible
$
RECOMMENDATION:
Date:
Screener:
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