Kansas > Local District Court > 3rd Judicial District (Shawnee County) > Domestic
Financial Affidavit For Court Appointed Attorney - Kansas
| Financial Affidavit For Court Appointed Attorney Form. This is a Kansas form and can be used in Domestic 3rd Judicial District (Shawnee County) Local District Court . |
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Financial Affidavit For Court-Appointed Attorney Obligor Name: Last First MI AgeSpouse if Married: Last First MI AgeAddress: Phone: ( ) Street City State/Zip Emergency Contact: Last First MI Address: Phone: ( ) Street City State/Zip EMPLOYMENT: Are you (check one): ___Employed ___Unemployed ___Self-employed Monthly Income Complete the information below for the past 12 months: EMPLOYER ADDRESS DATES OF EMPLOYMENT (YOUR) SPOUSE) __ If living with your parents or others to whom you look for support, I enter their monthly income. . . . . . . . N $ TOTAL C X 12 $ O Estimated Annual Inco me M EOTHER INCOME: Have you received within the past 12 months any other income, includin g from a business, rent payments, public assistance, support or other sources? ___ Yes ___No If yes, give the amount received and identify sources $ $ Total Annua l Income O A CASH: Have you any available cash or money in savings or checking accounts, c ertificates of deposit or other funds? T S ____ Yes ____ No Value$ H S E E PROPERTY: Do you own a home, land or other property? (Do not include any househo ld furnishings or clothing) R T ____ Yes ____ No S A. If yes, approximately how much is it worth?$ $ B. How much is still owed on it? $ C. Net value of property (A - B) $ Total Income, Other Income, Cash, and Property: O DEPENDENTS: Check one: ___Single ___Married ___Widowed ___Separated ___Divorced B Total Number of Dependents ______. List their names, ages, and relat ionship to you: L & I G D Debts/Monthly Bills: List your expenses for each of theA E following categories: T B Rent/House payment. . . . . . . . $ I T Food/Clothing/Medicine . . . . O S Utilities. . . . . . . . . . . . . . . . . . N Alimony/Child Support . . . . . S Installment Payments . . . . . . Other Payments . . . . . . . . . . $ TOTAL MONTHLY EXPENSES
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