Fillable Printable Financial Affidavit Form
Fillable Printable Financial Affidavit Form
Financial Affidavit Form
IN THE CIRCUIT COURT OF THE SIXTH JUDICIAL CIRCUIT,
IN AND FOR PINELLAS COUNTY, FLORIDA
Case No.:
Division:
,
Petitioner,
and
,
Respondent.
FAMILY LAW FINANCIALAFFIDAVIT (SHORT FORM)
(Under $50,000 Individual Gross Annual Income)
I, , 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.Monthlybusinessincomefromsourcessuchasself-employment,partnerships,
closecorporations,and/orindependentcontracts(grossreceiptsminusordinary
andnecessaryexpensesrequiredtoproduceincome) (□ Attachsheetitemizing
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
9a. From this case: $
9b. From other case(s):Add 9a and 9b
10.Monthly interest and dividends
11.Monthlyrentalincome(grossreceiptsminusordinaryandnecessaryexpenses
requiredtoproduceincome)(□Attachsheetitemizingsuchincomeand
expense items.)
12.Monthly income from royalties, trusts, or estates
13.Monthly reimbursed expenses and in-kind payments to the extent that they
reduce personal living expenses
14.Monthlygainsderivedfromdealinginproperty(notincludingnonrecurring
gains)
15.Any other income of a recurring nature (list source)
16.
1.$
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17. PRESENT MONTHLY GROSS INCOME (Add lines 1–16)TOTAL: 17. $
Florida Family Law Rules of Procedure Form 12.902(b), Family Law Financial Affidavit (Short Form) (09/06)
PRESENT MONTHLY DEDUCTIONS:
18.Monthlyfederal,state,andlocalincometax(correctedforfilingstatusand
allowable dependents and income tax liabilities)
a. Filing Status ____________
b. Number of dependents claimed _______
19.Monthly FICA or self-employment taxes
20.Monthly Medicare payments
21.Monthly mandatory union dues
22.Monthly mandatory retirement payments
23.Monthlyhealthinsurancepayments(includingdentalinsurance),excluding
portion paid for any minor children of this relationship
24.Monthlycourt-orderedchildsupportactuallypaidforchildrenfromanother
relationship
25.Monthly court-ordered alimony actually paid
25a. from this case: $
25b. from other case(s): Add 25a and 25b
18.$
19.
20.
21.
22.
23.
24.
25.
26. TOTAL DEDUCTIONS ALLOWABLE UNDER SECTION 61.30,
FLORIDA STATUTES (Add lines 18 through 25) TOTAL: 26. $
PRESENT NET MONTHLY INCOME (Subtract line 26 from line 17) 27. $
SECTION II. AVERAGE MONTHLY EXPENSES
A. HOUSEHOLD:
Mortgage or rent $
Property taxes $
Utilities $
Telephone $
Food $
Meals outside home $
Maintenance/Repairs $
Other: $
B. AUTOMOBILE
Gasoline $
Repairs $
Insurance $
C. CHILD(REN)’S EXPENSES
Day care $
Lunch money $
Clothing $
Grooming $
Gifts for holidays$
Medical/Dental (uninsured)$
Other: $
D. INSURANCE
Medical/Dental$
Child(ren)’s medical/dental$
Life$
Other: $
E. OTHER EXPENSES NOT LISTED ABOVE
Clothing$
Medical/Dental (uninsured)$
Grooming$
Entertainment$
Gifts$
Religious organizations$
Miscellaneous$
Other: $
$
$
$
$
$
$
F. PAYMENTS TO CREDITORS
MONTHLY
CREDITOR:PAYMENT
$
$
$
$
$
$
$
$
$
$
$
28. TOTAL MONTHLY EXPENSES (add ALL monthly amounts in
Florida Family Law Rules of Procedure Form 12.902(b), Family Law Financial Affidavit (Short Form) (09/06)
A through F above)28. $
SUMMARY
29. TOTAL PRESENT MONTHLY NET INCOME
(from line 27 of SECTION I. INCOME)
30. TOTAL MONTHLY EXPENSES (from line 28 above)
31. SURPLUS (If line 29 is more than line 30, subtract line 30 from line 29.
This is the amount of your surplus. Enter that amount here.)
32. (DEFICIT) (If line 30 is more than line 29, subtract line 29 from line 30.
This is the amount of your deficit. Enter that amount here.)
29. $
30. $
31. $
32. ($ )
SECTION III. ASSETS AND LIABILITIES
Usethenonmaritalcolumnonly if thisisa petition for dissolutionofmarriageandyoubelieveanitem is “nonmarital,”
meaningitbelongstoonlyoneofyouandshouldnotbedivided.Youshouldindicatetowhomyoubelievetheitem(s)or
debtbelongs.(Typically,youwillonlyusethiscolumnifproperty/debtwasowned/owedbyonespousebeforethemarriage.
Seethe“GeneralInformationfor Self-RepresentedLitigants”foundatthebeginningoftheseformsandsection61.075(1),
Florida Statutes, for definitions of “marital” and “nonmarital” assets and liabilities.)
A.ASSETS:
DESCRIPTIONOF ITEM(S).Listadescriptionofeachseparateitemownedby
you (and/or your spouse, if this is a petition for dissolution of marriage).
DONOTLIST ACCOUNT NUMBERS.√theboxnexttoanyasset(s)whichyou
are requesting the judge award to you.
Current Fair
Market Value
Nonmarital
(√ correct column)
husbandwife
□ Cash (on hand)$
□ Cash (in banks or credit unions)
□ Stocks, Bonds, Notes
□ Real estate: (Home)
□ (Other)
□ Automobiles
□ Other personal property
□ Retirement plans (Profit Sharing, Pension, IRA, 401(k)s, etc.)
□ Other
□
□
□
□
□
□
□ √ here if additional pages are attached.
Total Assets (add next column)$
Florida Family Law Rules of Procedure Form 12.902(b), Family Law Financial Affidavit (Short Form) (09/06)
B. LIABILITIES:
DESCRIPTIONOFITEM(S).Listadescriptionofeachseparatedebtowedby
you (and/or your spouse,if this is a petition for dissolution ofmarriage). DO NOT
LIST ACCOUNT NUMBERS. √ thebox nextto any debt(s)for which youbelieve
you should be responsible.
Current
Amount Owed
Nonmarital
(√ correct column)
husbandwife
□ Mortgages on real estate: First mortgage on home$
□ Second mortgage on home
□ Other mortgages
□
□ Auto loans
□
□Charge/credit card accounts
□
□
□
□ Other
□
□
□
□ √ here if additional pages are attached.
Total Debts (add next column)$
C. CONTINGENT ASSETS AND LIABILITIES:
INSTRUCTIONS: If you have any POSSIBLEassets (income potential, accrued vacation or sick leave, bonus, inheritance, etc.)
orPOSSIBLE liabilities(possible lawsuits, futureunpaid taxes,contingenttax liabilities,debts assumedby another),youmust
list them here.
Contingent Assets
√ the box next to any contingent asset(s) which you are requesting the judge award to you.
Possible Value
Nonmarital
(√ correct column)
husband
wife
□$
□
Total Contingent Assets$
Contingent Liabilities
√ the box next to any contingent debt(s) for which you believe you should be responsible.
Possible Amount
Owed
Nonmarital
(√ correct column)
husband
wife
□$
□
Total Contingent Liabilities$
SECTION IV. CHILD SUPPORT GUIDELINES WORKSHEET
A Child Support Guidelines Worksheet IS or WILL BE filed in this case. This case involves the
establishment or modification of child support.
A Child Support Guidelines Worksheet IS NOT being filed in this case. The establishment or
modification of child support is not an issue in this case.
Other party or his/her attorney:
Name:
Address:
City,State, Zip:
Fax Number:
IunderstandthatIamswearingoraffirmingunder oathtothetruthfulnessoftheclaims
madeinthisaffidavitandthatthepunishmentforknowinglymakingafalsestatementincludes
fines and/or imprisonment.
Dated:
Signature of Party
Printed Name:
Address:
City,State, Zip:
Telephone Number:
Fax Number:
STATE OF FLORIDA
COUNTY OF PINELLAS
Sworn to or affirmed and signed before me on by .
NOTARY PUBLIC or DEPUTYCLERK
[Print,type,orstampcommissionednameof
notary or deputy clerk.]
Personally known
Produced identification
Type of identification produced
CERTIFICATE OF SERVICE
IHEREBYCERTIFYthatatruecopyoftheforegoinghasbeenfurnishedbyU.S.Mailto,
____________________________________________________________________________________,
on this __ day of _________________, 20_____.
_______________________
BRIDGET HEPTNER, Esq.
2560 Gulf to Bay Boulevard
Suite 250
Clearwater, Florida 33765
(727) 726-9799
FBN: 0547107
SPN: 00607971
