Form A - Income & Expense Affidavit Page 2
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1
2Gas
$________________
$________________
Water
$________________
$________________
Cable
$________________
$________________
Telephone
$________________
$________________
Cell Phone
$________________
$________________
Educational Expenses:
$________________
$________________
________________________________
$________________
$________________
________________________________
$________________
$________________
________________________________
$________________
$________________
________________________________
$________________
$________________
________________________________
$________________
$________________
Other Expenses:
$________________
$________________
________________________________
$________________
$________________
________________________________
$________________
$________________
________________________________
$________________
$________________
________________________________
$________________
$________________
________________________________
$________________
$________________
________________________________
$________________
$________________
________________________________
$________________
$________________
________________________________
$________________
$________________
________________________________
$________________
$________________
________________________________
$________________
$________________
________________________________
$________________
$________________
________________________________
$________________
$________________
________________________________
$________________
$________________
TOTAL MONTHLY LIVING EXPENSES
$________________
III. FIXED DEBT
Obligee
Balance Due
Date of Last Payment
Monthly Payment
_________________
$________________
_________________
$________________
_________________
$________________
_________________
$________________
_________________
$________________
_________________
$________________
_________________
$________________
_________________
$________________
_________________
$________________
_________________
$________________
_________________
$________________
_________________
$________________
_________________
$________________
_________________
$________________
_________________
$________________
_________________
$________________
_________________
$________________
_________________
$________________
_________________
$________________
_________________
$________________
TOTAL FIXED DEBT $________________ TOTAL MONTHLY DEBT $________________
___________________________________
AFFIANT SIGNATURE
SWORN TO AND SUBSCRIBED before me this ____ day of ________________________,
20___, at _________________________, Louisiana.
___________________________________
NOTARY PUBLIC
THE FAMILY COURT
FORM A, p. 2 of 2
REVISED: NOV 2013
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