Financial Declaration - Traffic Petition
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1FINANCIAL DECLARATION - Traffic Petition
Docket Number: ________________
Full Name: __________________________________________ Age: ________ Date of Birth: ___________________
Address: ________________________________________________________ Telephone: _____________________
Street
City
Marital Status:
Single ______
Married ______
Divorced ______
Separated ______
Widowed ______
Name of wife/husband: ___________________________________ Children:
Number ______ Ages ___________
Social Security Number: _________________________________ Driver's License No. _______________________
EMPLOYMENT RECORD
SPOUSE EMPLOYMENT
Employer:
_______________________________
Employer:
_______________________________
Address:
_______________________________
Address:
_______________________________
City:
_______________________________
City:
___________________________
Type of Job:
_______________________________
Type of Job:
_______________________________
Gross Salary:
$__________________ (Week/Month)
Gross Salary:
$__________________ (Week/Month)
Take Home:
$__________________ (Week/Month)
Take Home:
$__________________ (Week/Month)
OTHER INCOME
LIST YOUR MONTHLY EXPENSES
Unemployment & Disability
$ ________________
Rent or House Payment
$ ________________
Social Security
$ ________________
Car Payments
$ ________________
Welfare, AFDC
$ ________________
Medical Payments
$ ________________
Veterans Benefits
$ ________________
Loan Payments
$ ________________
Workers Compensation
$ ________________
Clothing & laundry
$ ________________
Child Support Payments
$ ________________
Food
$ ________________
Support from parents
$ ________________
Other Payments
$ ________________
All Other Income
$ ________________
WHO DO YOU OWE?
Name
Monthly Payment
Balance Owed
WHAT DO YOU OWN? LIST VALUE
Cash
$ _______________________
____________________________________________
House:
$ _______________________
____________________________________________
Cars & Other Vehicles $ _______________________
____________________________________________
Life Insurance
$ _______________________
____________________________________________
Bank Accounts
$ _______________________
____________________________________________
____________________________________________
____________________________________________
Name of Bank
Branch
I declare under penalty of perjury that the foregoing Financial Declaration is true and correct and if sworn as a witness, I
could testify competently thereto.
Executed at ____________________, this ______ day of _____________, 200___ .
___________________________________________
Signature of Petitioner
Local form
TR01a (0511)
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