2.
List any lump sum income (bonus, gifts, inheritance, etc.) in excess of $500, expected to be received within the next six
months, not otherwise listed in this affidavit. Attach additional pages if needed.
Source
Value
$
3.
List all funds on deposit in any and all accounts in any bank, savings & loan, credit union, regulated investment
company, mutual fund or other financial institution. Account includes any of the following: checking, certificate of deposit
("CD"), investment, savings, individual retirement account ("IRA"), stock option, etc. Attach additional pages if needed.
Name & Address of
Name(s)
Financial Institution
Account Number
on Account
Balance
IV.
AFFIANT'S MONTHLY EXPENSES
List your ACTUAL expenses for your present household. If you expect changes in your expenses soon, attach a separate sheet with
your ESTIMATED expenses. If you are living with your parents or someone is helping you with your living expenses, please
identify that party _________________________________ and the amount of support provided ____________________.
A. MONTHLY EXPENSES
1. Housing
Rent or Mortgage (including taxes and insurance) ............................................. $
Utilities
a. Gas & Electric (level billing or average per month) ............................... $
b. Water & Sewer ...................................................................................... $
c. Basic Telephone (excluding long distance)........................................... $
d. Trash Collection: ................................................................................... $
Other: __________________________________________............................ $
HOUSING TOTAL ................................................................................................. $
(I)
2. Other
Grocery (include food, laundry & cleaning products/toiletries etc) ............ $
Gasoline & Oil ........................................................................................... $
Car Repairs ............................................................................................... $
Insurance: (life/auto/renter's) ____________________________ ................ $
Medical (not covered by insurance) ......................................................... $
Clothing ..................................................................................................... $
Internet ...................................................................................................... $
Other_______________________________________ .....................................
OTHER MONTHLY EXPENSES TOTAL .............................................................. $
(II)
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