Financial Affidavit Short Form Page 3
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1
2
3
4Mobile Homes
Contents of home
Life insurance/Annuities
Other:
Other:
Other:
Other:
Other:
Other:
Other:
Total Assets–>
H. Creditors
Creditor Name
Balance Owed
Monthly Payment
Total debts–>
I. Summary
Assets
Liabilities
Net Worth
J. Balance
Available income
Total - All Expenses
Balance
I AM AWARE THAT ANY MATERIALLY FALSE STATEMENT, KNOWINGLY MADE WITH THE INTENT TO DEFRAUD
OR MISLEAD SHALL SUBJECT ME TO THE PENALTY FOR PERJURY MAY BE CONSIDERED A FRAUD UPON THE
COURT.
I certify that a true and correct copy of this financial affidavit was ___Mailed ____faxed and mailed this ______________to:
_________________, _________________, _________________, (Fax: _________________).
_________________________
_________________, Affiant
Acknowledge before me on__________, _____ by _________________, who produced a _____________________ as identification
and who did take oath.
______________________________________
NOTARY PUBLIC#STATE OF FLORIDA
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