FINANCIAL AFFIDAVIT
STATE OF CONNECTICUT
COURT USE ONLY
SUPERIOR COURT
JD-FM-6 Rev. 1-08
FINAFF
P.B. 25-30
DOCKET NO.
FOR THE JUDICIAL DISTRICT OF
AT (Address of court)
NAME OF AFFIANT (Person submitting this form)
NAME OF CASE
PLAINTIFF
DEFENDANT
OCCUPATION
NAME OF EMPLOYER
ADDRESS OF EMPLOYER
A. WEEKLY INCOME FROM PRINCIPAL EMPLOYMENT (Use weekly average not fewer than 13 weeks)
DEDUCTIONS
AMOUNT/WEEK
DEDUCTIONS (Cont )
AMOUNT/WEEK
(Taxes, FICA, etc.)
GROSS WKLY WAGE FROM
$
$
PRINCIPAL EMPLOYMENT
$
1.
4.
$
$
TOTAL DEDUCTIONS
$
2.
5.
NET WEEKLY WAGE
$
$
$
3.
6.
B. ALL OTHER INCOME (Include in-kind compensation, gratuities, rents, interest, dividends, pension, etc.)
SOURCE OF INCOME
GROSS AMT/WK
SOURCE OF INCOME
GROSS AMT/WK
1.
GROSS WEEKLY INCOME
$
$
$
1.
FROM OTHER SOURCES
2.
WEEKLY
INCOME
DEDUCTIONS
AMOUNT/WEEK
DEDUCTIONS
AMOUNT/WEEK
TOTAL DEDUCTIONS
$
$
$
NET WEEKLY INCOME
$
$
FROM OTHER SOURCES
$
$
$
$
$
ADD "NET WEEKLY WAGE" FROM SECTION A,
AND "NET WEEKLY INCOME" FROM SECTION B,
$
$
AND ENTER TOTAL BELOW:
TOTAL NET
A.
$
$
$
WEEKLY INCOME
1. RENT OR MORTGAGE
11. DAY CARE
Gas/Oil
$
$
$
12. OTHER (specify below)
2. REAL ESTATE TAXES
Repairs
$
$
6. TRANSPOR-
TATION
Fuel
Auto Loan
$
$
$
Public
Electricity
$
$
$
Trans.
Medical/
Gas
$
$
$
2.
Dental
WEEKLY
Automo-
3. UTILITIES
Water
$
$
$
7. INSURANCE
bile
EXPENSES
PREMIUMS
Home-
Telephone
$
$
$
owners
Trash
Life
$
$
$
Collection
8. MEDICAL/DENTAL
Cable T.V.
$
$
$
9. CHILD SUPPORT
4. FOOD
$
$
$
(order of court)
TOTAL WEEKLY
10. ALIMONY
B.
5. CLOTHING
$
$
$
EXPENSES
(order of court)
CREDITOR (Do not include mortgages or loan
AMOUNT OF
BALANCE
WEEKLY
DATE DEBT INCURRED
balances that will be listed under assets.)
DEBT
DUE
PAYMENT
$
$
$
$
$
$
3.
$
$
$
LIABILITIES
(DEBTS)
$
$
$
$
$
$
$
$
$
TOTAL WEEKLY
C. TOTAL LIABILITIES (Total Balance Due on Debts)
$
D.
$
LIABILITY EXPENSE
(continued)
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