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Financial Affidavit NHJB-2065-FS - New Hampshire

Financial Affidavit Form. This is a New Hampshire form and can be used in Domestic Superior Court Statewide .
 Fillable pdf Last Modified 1/3/2013
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THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) FINANCIAL AFFIDAVIT 1. General Information Name Street Address Town/City, State, Zip Mailing Address, if different Date of Birth Social Security Number Highest Grade or Degree Completed Date of Marriage Date of Separation or Divorce 2. Children born to, or adopted by, the Parties (Full Name, DOB, and SSN) 4. Monthly Income - Miscellaneous AFDC, TANF, and Food Stamps Other Public Assistance Children's Income Child Support 5. Monthly Income Before Taxes Base Pay from Salary, Wages Overtime and Shift Differential Commissions, Tips, Bonuses Part-time Employment Self-employment Unemployment and Veteran's Benefits Disability, Workers' Compensation Pension and Retirement Benefits Social Security Benefits (SSA) Interest and Dividends Trust and Other Investment Income Rental Income and Business Profits All other sources Total Section 5 Monthly Income Date and Place of Last Employment 6. Monthly Expenses Court Ordered Support for Others State Income Taxes Mandatory Pension Health Insurance for Parties' Children Day Care for Parties' Children Total Section 6 Monthly Expenses Related Debt $ $ $ $ $ $ $ $ $ $ $ Page 1 of 5 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 2a. Number of people currently living in household including self: 3. Employment Information Name, Address, and Phone Number of Employer Job Skills 7. Assets Homestead Other Real Estate Primary Motor Vehicle Other Motor Vehicles Furniture and Appliances Checking Accounts Investments Life Insurance Business Interests Pensions Retirement Accounts NHJB-2065-FS (12/01/2011) Fair Market Value $ $ $ $ $ $ $ $ $ $ $ Additional Information American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: FINANCIAL AFFIDAVIT 8. Additional Assets - If you have an interest in any property which is held solely by or jointly with any other person or entity, and which has not already been disclosed, or if you are owed money from any source, please explain 9. Tax Return Information Year of last return filed Single or joint return My Total W-2s and 1099s = $ If Self-employed, check here and attach copy of most recent IRS Schedule C. 10. Insurance Life Company Type and Face Amount Beneficiaries Health Company Type Description of Coverage 11. Debts Who is debt owed to? Who owes debt? $ $ $ $ $ Balance 12. Retirement Plans Plan or Account Name Type Most Recent Value $ Value at Filing $ If Defined Benefit, status of vesting and description of Benefit Dental Company Description of Coverage 13. Attachments: Pay Stub Monthly Expenses Schedule C Other (describe) Check here if parties agree to waive Monthly Expenses form. 14. Additional Information I swear (affirm) that: A. To the best of my knowledge and belief, I have fully disclosed all income and all assets having any substantial value; and B. I have reasonably estimated the fair market value of each asset; and C. I understand that I have a duty to update the information provided in this financial affidavit for each court hearing; and D. I understand that if a support order is issued in this case obligating me to pay support, it shall be my responsibility to immediately provide the Court with any change of address in writing. If I fail to do so, I may be held in default, found in contempt of court and a warrant may be issued for my arrest. (See USO Standing Order SO-4C.) E. Rule 1.25-A Compliance -- Family Division Only: (Initial one) I have complied with Rule 1.25-A regarding mandatory disclosure; OR I understand my obligation to comply with Rule 1.25-A regarding mandatory disclosure. I have not fully complied with Rule 1.25-A due to: Date Signature State of , County of The person signing this financial affidavit appeared and signed this before me and took oath that the statements set forth in this Financial Affidavit, together with any attachments listed in section 13 above, are true to the best of his or her knowledge and belief. by This instrument was acknowledged before me on My commission expires: Affix seal, if any Signature of Notarial Officer / Title I certify that a copy of this financial affidavit (and any attachments) was this day mailed / given to (lawyer for other side, if any) (other side, if no lawyer) (OCSE, if State is a party): Date NHJB-2065-FS (12/01/2011) Signature Page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: FINANCIAL AFFIDAVIT NOTE: Round all numbers to the nearest dollar. To convert weekly expenses to monthly, multiply by 4.33. 1. Housing Rent Mortgage Payment Property Tax Condo Fee Home Maintenance Snow Removal and Lawn Care 2. Utilities Heating Oil Wood and Coal Propane and Natural Gas Telephone Electricity Cable Television Water and Sewer Trash Collection 3. Insurance Homeowner Renter Vehicle Health Dental Life Disability 4. Uninsured Health Care Medical Dental Orthodontics Eye Care/Glasses/Contacts Prescription Drugs Therapy and Counseling 5. Transportation Primary Vehicle Payment Other Vehicle Payments Vehicle Maintenance Gas and Oil Registration and Tax $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 6. General and Personal Groceries Meals Eaten Out Tobacco/Alcohol Products Clothing and Shoes Hair Care Toiletries and Cosmetics Pet Food and Care Church and Charities Laundry and Dry Cleaning Gifts Newspapers and Magazines Education (personal) Dues and Memberships Vacations Entertainment and Recreation Visitation Expenses 7. Children's Expenses and Activities Children's Clothing and Shoes Diapers Day Care School Supplies School Lunches Tuition and Lessons Sports and Camp 8. Financial Federal Income Tax Social Security and Medicare Loan Payments Other Debts Savings 401(k) IRA Other Retirement Plans $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ TOTAL MONTHLY EXPENSES $ 9. Other Expenses NHJB-2065-FS (12/01/2011) Page 3 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: FINANCIAL AFFIDAVIT THE STATE OF NEW HAMPSHIRE General Instructions for Completing the Financial Affidavit Form NHJB-2065-F A. When this form is needed - You must fill out and file this form with the Court. If you are the petitioner or respondent in a divorce, legal separation, or civil union dissolution case. If you are the petitioner or respondent in an after-divorce, custody/parenting, child support, or paternity case. If either side is requesting child suppo
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