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Family Law Financial Affidavit (Short Form) Page 3

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IN THE CIRCUIT COURT OF THE

JUDICIAL CIRCUIT,

IN AND FOR

COUNTY, FLORIDA

Case No.:

Division:

Petitioner,

and

Respondent.

FAMILY LAW FINANCIAL AFFIDAVIT (SHORT FORM)

(Under $50,000 Individual Gross Annual Income)

I, {full legal name}

, being sworn, certify that the

following information is true:

My Occupation:

Employed by:

Business Address:

Pay rate: $

( ) every week ( ) every other week ( ) twice a month ( ) monthly

( ) other:

___ Check here if unemployed and explain on a separate sheet your efforts to find

employment.

SECTION I. PRESENT MONTHLY GROSS INCOME:

All amounts must be MONTHLY. See the instructions with this form to figure out money

amounts for anything that is NOT paid monthly. Attach more paper, if needed. Items included

under “other” should be listed separately with separate dollar amounts.

1. _______ Monthly gross salary or wages

2. _______Monthly bonuses, commissions, allowances, overtime, tips, and similar payments

3. _______Monthly business income from sources such as self-employment, partnerships,

close corporations, and/or independent contracts (gross receipts minus ordinary and

necessary expenses required to produce income) (Attach sheet itemizing such income and

expenses.)

4. _______Monthly disability benefits/SSI

5. _______Monthly Workers’ Compensation

6. _______Monthly Unemployment Compensation

7. _______Monthly pension, retirement, or annuity payments

8. _______Monthly Social Security benefits

9. ______Monthly alimony actually received (Add 9a and 9b)

a. From this case: $ _______

b. From other case(s): _______

10. _______ Monthly interest and dividends

Florida Family Law Rules of Procedure Form 12.902(b), Family Law Financial Affidavit (Short Form) (10/11)

Family Law Financial Affidavit (Short Form) Page 3

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