State Of Alaska - Financial Statement Affidavit Template Page 4

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16. OATH
I declare, under oath, that my Financial Statement is true.
DO NOT SIGN THIS AFFIDAVIT UNTIL YOUR SIGNATURE CAN BE WITNESSED.
a. _______________________________
b. ___________________________________________________
Date
Signature of Appellant/Parent (of appellant under 18)
Subscribed and worn to or affirmed before me on __________________________________, 19 _______ in
________________________________, Alaska.
c. ___________________________________________________
(SEAL)
Notary Public / Deputy Clerk of Court
My commission expires: _________________________________
FOR COURT USE ONLY - DO NOT COMPLETE
17. FINANCIAL SUMMARY
a. Total family income for the past 12 months
$_________________
b. Total assets (equity)
$_________________
Cash
$_________________
c. Total debts
$_________________
d. Total family income each month
$___________________
e. Total family expenses each month
$___________________
Amount behind
$_________________
f. Total discretionary income each month
$___________________
h. I recommend that this request be GDenied. GApproved.
i. Reasons: _____________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
j. _______________________________ k. __________________________________________________
Date
Signature of Deputy Clerk
COA Financial Statement Affidavit-4 (Rev. 1/98)

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