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Name: ___________________________________ Address: _________________________________ City, State, ZIP: ____________________________ Daytime Telephone No: ______________________ Representing Self, Without a Lawyer ARIZONA SUPERIOR COURT, PIMA COUNTY _____________________________________ Petitioner v. _____________________________________ Respondent Case No._______________ CHILD SUPPORT FINANCIAL AFFIDAVIT Prepared By Petitioner Respondent Current As Of __________________ INSTRUCTIONS: Prepare this form following the instructions on the attached instruction sheet. Failure to provide the information required may result in the Court imposing sanctions against you pursuant to Rule 71 and/or 76D, Arizona Rules of Family Law Procedure. NECESSARY MONTHLY EXPENSES (For minor children in this case) Child(ren)'s Medical & INCOME Dental Insurance $_____________ GROSS PAYCHECK $__________ Childcare/Sitter $_____________ weekly twice mo.* Other Spousal Maintenance $_____________ monthly every 2 weeks Child Support for *For example, the 1st and 15th Other Child(ren) $_____________ Child(ren)'s Education $_____________ OTHER GROSS MONTHLY INCOME Pension/Retirement $_____________ Social Security/SSI $__________ Extraordinary Child Expenses (please list) Dividends/Interest $__________ ____________________ $_____________ GA/TANF $__________ ____________________ $_____________ Spousal Maintenance $__________ ____________________ $_____________ Other_________________ $__________ Total Monthly Expenses $_____________ Total other gross income $__________ ANNUAL PARENTING TIME DAYS Summer periods: __________ Holidays, school breaks: __________ Weekends: __________ Weekdays: __________ Other: __________ Please explain: _______________________________________________ ____________________________________________________________________________ Total Annual Parenting Time Days: __________ Present Occupation ______________________ Starting Date: ______________ Name of present employer _____________________________________________________ Address _____________________________________________________ Telephone No. _____________________________________________________ Prior Occupation ________________________ Starting Date: ______________ Monthly Pay: _______________ Ending Date: _______________ 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Name of prior employer _______________________________________________________ Address _______________________________________________________ Telephone No. _______________________________________________________ If not currently employed, why?_________________________________________________ Do you expect to work? yes no When? ________ Anticipated Occupation____________ Full name(s) and age(s) of ALL minor child(ren) residing with you (attach an additional page, if needed): ____________________________________________________________________________ ____________________________________________________________________________ Are you or your spouse pregnant? yes no (attach an additional page, if needed): If yes, estimated delivery date: ___________ Physical defect or organic disease suffered by you or your minor children: ________________ ____________________________________________________________________________ ____________________________________________________________________________ List all bank accounts in your name, in the names of both spouses, or in which you have an interest, including checking, savings, credit union, and certificates of deposit. Type of Account # Bank and Branch Location Account (last 4 digits) Average Balance List all cash under your control and any stocks, shares, and/or bonds in your name, in the names of both spouses, or in which you or both you and your spouse have an interest. ____________________________________________________________________________ ____________________________________________________________________________ Attorney fees paid to date $_________________ Court costs paid to date $_______________ STATE OF ARIZONA ) ) ss. County of Pima ) _____________________________________, being first duly sworn, deposes and says that he/she has read the foregoing Financial Affidavit and knows the contents thereof, and that the allegations therein contained are true in substance and in fact, except those made on information and belief, when are believed to be true. DATED this ________ day of __________________, 20____. Signature: _____________________________ Petitioner Respondent SUBSCRIBED AND SWORN TO before me this _____day of _____________, 20____. My Commission Expires: ______________________ 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com ________________________________ Notary Public