Form Coa - Financial Statement Affidavit Page 3
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414. INCOME INFORMATION (CONT.)
f. Your total NET monthly income from:
g. Your Spouse’s total NET monthly income from:
1) Wages: $______________________________
1) Wages: $______________________________
2) Public Assistance: $_____________________
2) Public Assistance: $_____________________
3) Unemployment: $_______________________
3) Unemployment: $_______________________
4) Other: $_______________________________
4) Other: $_______________________________
Explain:_______________________________
Explain:_______________________________
15. FAMILY ASSETS (things you own or are buying)
1) Family Assets
2) Value
3) Amount still owed
4) For court use only
a. Cash
$
b. Bank Account - checking
$
c. Bank Accounts - savings
$
d. Securities
$
e. Pension Plans/Annuities
$
f. Life Insurance (cash value/dividends)
$
g. Land, Homes, Trailers
$
$
h. Home Furnishings
$
$
i. TV, Stereo, VCR, Computer
$
$
j. Motor Vehicles
$
$
k. Snow Machines, Boats, ATVs,
Motorcyles, Airplanes
$
$
l. Jewelry, Precious Metals/Stones
$
$
m. Furs
$
$
n. Collections (coins, ivory, etc.)
$
$
o. Tools & Guns
$
$
p. Sports Equipment
$
$
q. Fishing Gear
$
$
r. Limited Entry Permit(s)
$
$
s. Businesses
$
$
t. Other (Specify): i._______________
$_______________ $________________
ii.____________________________
$_______________ $________________
$
$
u. TOTALS
v. Specify any of above you need to earn your living and explain why:______________________________
_______________________________________________________________________________________
COA Financial Statement Affidavit-3 (Rev. 1/98)
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