Domestic Relations Financial Affidavit - Pataula Judicial Circuit Page 3
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9Workers’ Compensation Benefits
$
Unemployment Benefits
$
Judgments from Personal Injury or other Civil Cases
$
Gifts (cash or other gifts that can be converted to cash)
$
Prizes/Lottery Winnings
$
Alimony and Maintenance from Persons not in this Case
$
Assets which are used for support of family
$
Fringe Benefits (if significantly reduce living expenses)
$
Any Other Income (do NOT include means-tested public
$
assistance, such as TANF or food stamps)
$
TOTAL GROSS MONTHLY INCOME:
B.
Affiant’s Net Monthly Income from Employment
$
Gross Wage minus withheld federal, state and FICA taxes
Affiant’s Pay Period (i.e. weekly, monthly, etc.)
Number of Exemptions Claimed:
4.
ASSETS
(If you claim or agree that all or part of an asset is non-marital, indicate the
non-marital portion under the appropriate spouse’s column and state the
amount and the basis: pre-marital, gift, inheritance, source of funds, etc.)
Description
Value
Separate Asset
Separate
Basis of the
of Husband
Asset of Wife
Claim
Cash
$
Stocks, Bonds
$
CD’s, Money Market
$
Bank Accounts:
$
$
$
Pataula Judicial Circuit
Domestic Relations Financial Affidavit - Revised 2016
Page 3 of 9
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