Form Coa - Financial Statement Affidavit Page 2
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413. MONTHLY EXPENSES
1) Expense
2) Your share of payment
3) Balance owed
4) Amount past due
a. Housing: Rent/Mortgage
$
$
$
b. Utilities: Gas/Electric/
Water/Garbage
$
$
$
c. Telephone
$
$
$
d. Food
$
$
$
e. Transportation (gas/bus)
$
$
$
f. Car payment
$
$
$
g. Insurance
$
$
$
h. Child Support/Alimony
$
$
$
i. Loans/Credit Card (List):
i.______________________
$____________________ $_________________ $__________________
ii.______________________
$____________________ $_________________ $__________________
iii.______________________
$___________________
$_________________ $__________________
iv.______________________
$___________________
$_________________ $__________________
v. ______________________
$___________________
$_________________ $__________________
j. Medical (not covered by
insurance)
$
$
$
k. Child Care
$
$
$
l. IRS Back Taxes
$
$
$
m. Debts (List):
i._______________________ $____________________ $_________________ $__________________
ii._______________________ $___________________
$_________________ $__________________
iii._______________________ $___________________
$_________________ $__________________
iv._______________________ $___________________
$_________________ $__________________
n. TOTALS
$
$
$
14. INCOME INFORMATION
a. Number of Permanent Fund Dividend checks received by your family within the
past year
b. Your total net income (after taxes, but before other deductions) in the past 12
$
months
c. Your spouse’s total net income during the past 12 months
$
d. Any money you expect to receive in the next 6 months (e.g. settlements,
$
annuities)
e. Are you a seasonal employee? GNo GYes (Specify)
COA Financial Statement Affidavit-2 (Rev. 1/98)
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Parent category: Legal