Les Form Afsu-10 - Financial Affidavit - State Of Florida Department Of Labor And Employment Security Page 3

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DOES ANYONE CONTRIBUTE TO YOUR
Life
$ _________
INCOME
OR
HELP
PAY
YOUR
EXPENSES
Other:
$ _________
(SPOUSE, ROOMMATE, ETC)?
YES
___________________________________
$ _________
NO
IF "YES", COMPLETE THE FOLLOWING:
___________________________________
$ _________
Name of
Relationship
Total Monthly
___________________________________
$ _________
Contributor
to Claimant
Dollar Amount
of Contribution
OTHER EXPENSES NOT LISTED ABOVE
______________
______________
$ _____________
___________________________________
$ _________
______________
______________
$ _____________
___________________________________
$ _________
______________
______________
$ _____________
___________________________________
$ _________
TOTAL
$ _____________
___________________________________
$ _________
AVERAGE
___________________________________
$ _________
ITEM 2 - HOUSEHOLD
MONTHLY
EXPENSES
___________________________________
$ _________
Mortgage or rent payments
$ _________
TOTAL HOUSEHOLD EXPENSES:
$ _________
Property taxes and insurance
$ _________
PAYMENTS TO CREDITORS:
Electricity
$ _________
TO
BALANCE
MONTHLY
WHOM
DUE
PAYMENT
Water, garbage and sewer
$ _________
Telephone
$ _________
______________
$ _____________
$ _____________
Fuel oil or natural gas
$ _________
______________
$ _____________
$ _____________
Pest control
$ _________
______________
$ _____________
$ _____________
Food and grocery items
$ _________
______________
$ _____________
$ _____________
Other:
$ _________
______________
$ _____________
$ _____________
___________________________________
$ _________
______________
$ _____________
$ _____________
___________________________________
$ _________
TOTAL MONTHLY PAYMENTS TO
CREDITORS:
$ _________
TOTAL MONTHLY EXPENSES
$ _________
AUTOMOBILE:
Loan payment
$ _________
SUMMARY OF INCOME & EXPENSES:
Auto tags and license
$ _________
TOTAL MONTHLY NET INCOME
$ _________
Insurance
$ _________
MONTHLY CONTRIBUTION - OTHERS
$ _________
Other
$ _________
SUBTOTAL
$ _________
INSURANCES:
LESS TOTAL MONTHLY EXPENSES
$ _________
Health
$ _________
BALANCE (+ or -)
$ _________
LES Form AFSU-10 (06/29/94)
Page 3 of 4

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