Financial Affidavit In Support Of Petition For Waiver Of Fees {2}

IN DISTRICT COURT, COUNTY, STATE OF NORTH DAKOTA , Plaintiff, vs. , Defendant. } } } } } } } } FINANCIAL AFFIDAVIT IN SUPPORT OF PETITION FOR WAIVER OF FEES DATE: Civil No. STATE OF NORTH DAKOTA COUNTY OF } } } ss. I, A. ASSETS I have cash on hand: , being first duly sworn state as follows: $ $ $ I have on deposit in financial institutions: I have stocks and bonds in the amount of: Total Other assets and approximate value are (list): ITEM VALUE $ $ $ $ $ Total (Attach additional schedules as needed) IN POSSESSION OF Total Assets $ American LegalNet, Inc. www.FormsWorkFlow.com B. LIABILITIES. CREDITORS UNPAID BALANCE $ $ $ $ $ $ TOTAL (Attach additional schedules as needed) $ $ $ $ $ $ MONTHLY PAYMENT Total Liabilities: C. INCOME. My monthly income, and that of my spouse, is as follows: AFFIANT GROSS INCOME DEDUCTIONS FEDERAL TAX FICA MEDICARE STATE TAX HEALTH INSURANCE RETIREMENT SAVINGS OTHER TOTAL DEDUCTIONS NET INCOME $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ SPOUSE My pay period is every __________________________. My spouse's pay period is every __________________________. American LegalNet, Inc. www.FormsWorkFlow.com D. EXPENSES. My current monthly expenses to support myself and my child(ren) are as follows: HOUSE/RENT PAYMENT GAS/ELECTRICITY HOMEOWNER'S/RENT INSURANCE WATER TELEPHONE CABLE/SATELLITE TELEVISION FOOD AND HOUSEHOLD ITEMS CLOTHING LAUNDRY LIFE INSURANCE AUTOMOBILE INSURANCE MEDICAL INSURANCE TRANSPORTATION CHILD CARE SCHOOL EXPENSES UNREIMBURSED MEDICAL, DENTAL, OPTICAL NEWSPAPER AND MAGAZINES DONATIONS ENTERTAINMENT MISCELLANEOUS TOTAL $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ American LegalNet, Inc. www.FormsWorkFlow.com DATED: My Signature (Sign only in presence of notary public or Clerk of Court) Street Address City/State/Zip Subscribed and sworn to before me on , 20______. Notary Public or Clerk of Court American LegalNet, Inc. www.FormsWorkFlow.com