Financial Affidavit Form
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FINANCIAL AFFIDAVIT
State of
______________________
)
County of
____________________
)
On _________________before me, ____________________________________, personally
appeared _________________________________, personally known to me (or proved to me
on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the
within instrument and acknowledged to me that he/she/they executed the same in his/her/their
authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s),
or the entity upon behalf of which the person(s) acted, executed the instrument and was sworn
and says that the following statement of affiant's income, assets and liabilities is true:
Occupation
___________________________________________________________________
Employed By
_________________________________________________________________
Business Address
______________________________________________________________
Pay Period
___________________________________________________________________
Rate of Pay
___________________________________________________________________
Social Security #
______________________________________________________________
ITEM 1: INCOME (Averaged on
________________
basis):
Average GROSS Wage
$____________
Less Deductions
Federal Income Tax
$____________
This product does not constitute the rendering of legal advice or services. This product is intended for informational use only and is not a substitute for
legal advice. State laws vary, so consult an attorney on all legal matters. This product was not prepared by a person licensed to practice law in this state.
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