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Financial Affidavit-Petition For Consideration Of Financial Obligation (Long Form) - Georgia
| Financial Affidavit-Petition For Consideration Of Financial Obligation (Long Form) Form. This is a Georgia form and can be used in Civil State Court Chatham Local County . |
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Financial Affidavit / Petition for Consideration of Financial Obligation Please print legibly PETITIONER'S NAME The person named above hereby petitions for remission, reduction or waiver of certain financial obligations for reasons shown in this document. Included, herein, please find a description of all such obligations and the reasons for which special consideration is being sought. Respectfully submitted this ______ day of _______________________, 200_____ _______________________________________________ (Signature ) Petitioner BACKGROUND INFORMATION OBLIGATION ONE DATE OBLIGATION INCURRED: ORIGINAL AMOUNT FOR: (Do not list real estate or automobiles here) AMOUNT PAID: UNPAID BALANCE: #REF! EXPLAIN ANY SPECIAL CIRCUMSTANCES ABOUT THIS OBLIGATION and what, if any, consideration is being sought and why. 1 2 3 OBLIGATION TWO DATE OBLIGATION INCURRED: ORIGINAL AMOUNT FOR: AMOUNT PAID: UNPAID BALANCE: #REF! EXPLAIN ANY SPECIAL CIRCUMSTANCES ABOUT THIS OBLIGATION and what, if any, consideration is being sought and why. 1 2 3 OBLIGATION THREE DATE OBLIGATION INCURRED: ORIGINAL AMOUNT FOR: AMOUNT PAID: UNPAID BALANCE: #REF! EXPLAIN ANY SPECIAL CIRCUMSTANCES ABOUT THIS OBLIGATION and what, if any, consideration is being sought and why. 1 2 3 OBLIGATION FOUR DATE OBLIGATION INCURRED: ORIGINAL AMOUNT FOR: AMOUNT PAID: UNPAID BALANCE: #REF! EXPLAIN ANY SPECIAL CIRCUMSTANCES ABOUT THIS OBLIGATION and what, if any, consideration is being sought and why. 1 2 3 American LegalNet, Inc. www.USCourtForms.com PAGE 2 Financial Affidavit and Petition for Reduction of Financial Obligation I RESPECTFULLY REQUEST REMISSION OR WAIVER OF CERTAIN FINANCIAL OBLIGATION(S) SHOWN BELOW FOR THE REASONS INDICATED: TOTAL OBLIGATIONS 1. 2. 3. 4. AMOUNT PAID BALANCE I HEREBY SUBMIT THIS FORM ALONG WITH PROPER DOCUMENTATION CONCERNING MY INCOME AND EXPENSES. I DO UNDERSTAND THAT MY REQUEST FOR CONSIDERATION IS BASED UPON MY FINANCIAL CIRCUMSTANCES WHICH MUST BE , AND I AGREE TO, DISCLOSE FOR CONSIDERATION OF THIS PETITION. I ALS0 REALIZE THAT I AM REQUIRED TO SUBMIT THOSE ITEMS MARKED BELOW WITH THIS PETITION. ______ 1. MY LAST THREE (3) PAY STUBS ______ 3. PROOF OF OTHER INCOME, IF ANY ______ 2. COPIES OF ALL BILLS REFERENCED ______ 4. COPY OF TAX RETURN -LAST YEAR REQUESTER'S INITIALS: ______ 5. IF DISABLED, OFFICIAL PROOF (DISABILITY AWARD LETTER) ______ 6. IF RECEIVING SOCIAL SECURITY, STATEMENT OF BENEFITS Income and expense considerations are based upon support provided for the petitioner and the persons listed below: How many legal dependents do you have? ________ Please list each dependent, their age and relationship to you. NAME AGE RELATIONSHIP LIVES WITH ME ? Circle Yes or No; if no, with whom? YES NO YES NO YES NO YES NO YES NO YES NO INCOME 1. For those now employed, your current job . . . . Employer's name Address Street Address Date Started: Position: NUMBER OF HOURS WORKED 2. Your previous Job: Employer's name Address Date Started: Position: Number hours worked: 3. Your previous Job: Employer's name Address Date Started: American LegalNet, Inc. www.USCourtForms.com City / State / Zip Next Review: Do you expect a raise Telephone # New wkly Salary $ Date Ending: Date of Last (If scheduled) (If scheduled to end) Raise: Comments (Avg Per Wk) $ Weekly Salary Street Address Date Ended: ENDED City / State / Zip Reason for Leaving: $ LEAVING: Telephone # Per Wk / Mo (circle one) Avg Per Wk/ Mo (circle one) Comments Street Address Date Ended: ENDED City / State / Zip Reason for Leaving: $ LEAVING: Telephone # Position: (Avg Per Wk) Per (circle one) Week / Month Number hours worked: Comments:_________________________________________________________ PAGE 3 Financial Affidavit and Petition for Reduction of Financial Obligation FOR THOSE NOW UNEMPLOYED . . . . Highest level of education / Any special skills_____________________________________________________________________________ Your last employment, when did it stop and why?__________________________________________________________________________ Why aren't you working? _____________________________________________________________________________________________ When was the last you ACTIVELY looked for a job?_________________________________________________________________________ Name any employment services and dates you contacted them_______________________________________________________________ Name any job training services and dates you contacted them________________________________________________________________ Are you getting any assistance from any of the following? If so, please indicate the monthly amounts: AFDC ALIMONY UNEMPLOYMENT FOOD STAMPS TRUST FUND INVESTMENT DIVIDENDS ANY CLAIMS / SETTLEMENTS DISABILITY CHILD SUPPORT WORKER'S COMPENSATION SOCIAL SECURITY PENSION OTHER INCOME WAGES (monthly) $0.00 # (From all Sources shown above) TOTAL MONTHLY INCOME: MONTHLY EXPENSES: The amounts of money paid by you for each of the following: HOUSING: (Rent/Lease/Mortgage) Person / Company to whom this is paid HOUSING UTILITIES : Water & Sewage Garbage Pickup Gas Electric Power Telephone Cable Other Utilities UTILITIES Car Insurance Gasoline Food Alimony Payments Loan Payments Clothing School AUTO EXPENSES Medical Insurance Cellular/ Car Phone Other Payments OTHER EXPENSES AUTO EXPENSES Car Payments Car Maintenance OTHER EXPENSES Child Support Beeper / Pager Medical Expenses Internet Service Household Expenses TOTAL EXPENSES: Cash (Not Savings) Checking Acct(s) Other Assets Other Assets Explain on Page 4 ASSETS: Real Estate (FMV)* Less Amount Owed Automobile(s) (FMV)* Less Amount Owed * FMV=Fair Market Value Net Real Estate Stocks/Bonds Retirement Acct(s) Net Auto Value Any Inheritances, Name: Lottery Winnings, Name: Any Legal/Insurance Settlements, Name: Any savings account, Institution: Other Assets not shown above: Other Assets not shown above: American LegalNet, Inc. www.USCourtForms.com TOTAL ASSETS: PAGE 4 Financial Affidavit and Petition for Reduction of Financial Obligation Net Worth TOTAL ASSETS: TOTAL LIABILITIES: NET WORTH: Monthly Situation TOTAL INCOME: TOTAL EXPENSES: $0 NET INCOME: COMMENTS 1. In the space provided below, provide any additional comments for consideration, if any. 2. If your NET INCOME is less than $ 0.00, please explain how you now provide for yourself and for your dependants. Otherwiae, INITIAL below to indicate if you have any additional comments. __________ I HAVE NOTHING FURTHER TO ADD. __________ PLEASE CON
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