Financial Affidavit - Pinellas County, Florida
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1IN THE CIRCUIT COURT OF THE SIXTH JUDICIAL CIRCUIT
IN AND FOR PINELLAS COUNTY, FLORIDA
IN THE INTEREST OF
UCN:
____________________________________
_______________________________,
Ref:
____________________________________
Petitioner
vs
________________________________/
Respondent
FINANCIAL AFFIDAVIT
I, ________________________________, being sworn, certify that the following information is true:
1. Date of Birth:_____________________________________ Phone:_________________
Address:______________________________________ City:____________________ State: ___ Zip: _________
2. Employer:______________________ Address:__________________________ Phone #:_______________
Pay rate: $ ____________ every week ( ) other week ( ) twice a month ( ) monthly ( ) other: ___________
ο check here if unemployed and explain on a separate sheet of paper your efforts to find employment.
3. Income.
Monthly gross salary or wages
$ ______________
Monthly disability benefits/SSI
______________
Monthly worker’s compensation
______________
Monthly unemployment compensation
______________
Monthly social security benefits
______________
Any other monthly income (list nature) _________________________
______________
Total GROSS monthly income:
______________
4. Deductions from income.
Note: Federal Income tax/social security/medicare withholdings are calculated automatically.
Monthly health insurance premiums you pay for child(ren) only
_______________
Monthly childcare expenses you pay for child(ren) under 12
_______________
Monthly mandatory amount you pay for retirement
_______________
Monthly amount you have been ordered to pay for child support for
other child(ren) NOT the subject of this case (list name(s) of child(ren))
________________________________________________________
_______________
5. Net monthly income:
6. Number of dependents you claim on income tax form:
______
______________________________________________
Signature
Sworn to before me this _________day of ___________, 200______.
______________________________________________
Circuit Judge
OR
State of Florida
County of ___________________________
The foregoing instrument was acknowledged before me this _______ day of ____________,
20___, by _________________________________, who is personally known to me or has produced
_____________________________ as identification.
___________________________
____________________________
Notary Public/Deputy Clerk
Commission Number
State of Florida
My commission expires:
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