Les Form Afsu-10 - Financial Affidavit - State Of Florida Department Of Labor And Employment Security Page 2
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4FINANCIAL AFFIDAVIT
STATE OF FLORIDA
COUNTY OF ____________________
BEFORE ME, this day personally appeared _____________________________________, who being duly sworn,
deposes and says that the following information is true and correct according to his/her best knowledge and belief:
Rental
income
(gross
receipts
minus
ITEM 1 - EMPLOYMENT AND MONTHLY INCOME
ordinary and necessary expenses required
to produce income)
$ _________
OCCUPATION: __________________________________
EMPLOYED BY: _________________________________
Income from royalties, trusts, or estates
$ _________
ADDRESS: _____________________________________
Reimbursed
expenses
and
in
kind
payments to the extent that they reduce
_______________________________________________
personal living expenses
$ _________
SOC. SEC. #: ___________________________________
Gains derived from dealing in property (not
including non-recurring gains
$ _________
PAY PERIOD: ___________________________________
Itemize any other income of a recurring
nature
$ _________
RATE OF PAY: __________________________________
TOTAL MONTHLY INCOME
$ _________
AVERAGE GROSS MONTHLY INCOME
LESS DEDUCTIONS
FROM EMPLOYMENT
$ _________
Bonuses,
commissions,
allowances,
Federal, state and local income taxes
overtime, tips and similar payments
$ _________
(corrected for filing status and actual
number of withholding allowances)
$ _________
Business income from sources such as self-
FICA or self-employment tax (annualized)
$ _________
employment,
partnership,
close
corporations and/or independent contracts
Mandatory union dues
$ _________
(gross
receipts
minus
ordinary
and
necessary expenses required to produce
Mandatory retirement
$ _________
income)
$ _________
Disability benefits
$ _________
Health insurance payments
$ _________
Workers' compensation
$ _________
Court-ordered
support
payments
for
children actually paid
$ _________
Pension, retirement, annuity payments
$ _________
TOTAL DEDUCTIONS
$ _________
Social security benefits
$ _________
TOTAL MONTHLY INCOME
$ _________
Spousal support received from previous
LESS TOTAL DEDUCTIONS
$ _________
marriage
$ _________
Interest and dividends
$ _________
NET MONTHLY INCOME
$ _________
LES Form AFSU-10 (06/29/94)
Page 2 of 4
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