Domestic Relations Financial Affidavit Page 4
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6(4) A
(continued)
Separate
Separate
Basis of the Claim
SSETS
(pre-marital, gift,
Asset of
Asset of
inheritance, etc.)
Description
Value
Husband
Wife
Life Insurance (net cash value)
$
$
$
Furniture / Furnishings
$
$
$
Jewelry
$
$
$
Collectibles
$
$
$
Other Assets (specify):
$
$
$
$
$
$
$
$
$
$
$
$
TOTAL ASSETS
(5)(A) A
M
E
Y
Y
H
VERAGE
ONTHLY
XPENSES FOR
OU AND
OUR
OUSEHOLD
HOUSEHOLD EXPENSES
Mortgage or Rent Payments
$
Gas
$
Property taxes
$
Repairs & Maintenance
$
Homeowner’s / Renter’s Insurance
$
Lawn Care
$
Electricity
$
Pest Control
$
Water
$
Cable TV / Internet Access
$
Garbage & Sewer
$
Misc. Household & Grocery Items
$
Telephones
Meals Outside Home
$
Residential Lines
$
Other (specify)
$
Cellular Telephones
$
$
AUTOMOTIVE
Gasoline & Oil
$
Auto Tags / Registration / License
$
Repairs & Maintenance
$
Insurance
$
OTHER VEHICLES (boats, trailers, RVs, etc.)
Gasoline & Oil
$
Tags / Registration / License
$
Repairs & Maintenance
$
Insurance
$
Domestic Relations Financial Affidavit -
Page 4 of 6
rev. DRAFT January 8, 2007
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