Affidavit Of Financial Status | Pdf Fpdf Doc Docx | Kansas

Affidavit Of Financial Status

Kansas/Federal/District Court/
Affidavit Of Financial Status | Pdf Fpdf Doc Docx | Kansas

Affidavit Of Financial Status Form

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This is a Kansas form that can be used for District Court within Federal.

Last updated: 8/26/2015
Revised 12/2012 IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF KANSAS _________________________________ Plaintiff(s), vs. ________________________________ ________________________________ Defendant(s). ) ) ) ) ) ) ) ) ) ) Case No. _________________________ AFFIDAVIT OF FINANCIAL STATUS1 I, _____________________________________, state that I am the plaintiff in this case and that the following information regarding my current financial status is true. I. PERSONAL DATA AND MARITAL STATUS: A. My address: My telephone: My age :_____________ B. Single: _____ Married: _____ Separated: _____ Divorced: _____ Spouse's name:______________________________________ Spouse's age: _____________ Spouse's address (if different from mine): _____________________________ Spouse's telephone (if different from mine): _________________ Access to this document is restricted pursuant to the court's policy to protect the personal privacy interest of the parties. American LegalNet, Inc. www.FormsWorkFlow.com 1 C. Names of dependents who live with me or who I am legally required to support financially: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Ages of dependents: ____________________________________________________________ Relationship of dependents to me: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Amount of monthly support I give each dependent: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ II. EMPLOYMENT A. Currently employed? Yes ____ No______ If currently employed: Name of employer: ________________________________________________ Address of employer: ______________________________________________ Employer's telephone: ______________________________________________ Length of employment: _____________________________________________ Job title or description: _____________________________________________ Net (take home) income: Monthly $__________ or Weekly $__________ Does employer provide health insurance? Yes ____ No _____ 2 American LegalNet, Inc. www.FormsWorkFlow.com If employer provides health insurance, what kind? ____________________________________________________________ ____________________________________________________________ B. Previous Employment (answer only if currently unemployed) . Name of employer: ________________________________________________ Address of employer: ______________________________________________ Employer's telephone: _____________________________________________ Length of employment: ____________________________________________ Job title or description: _____________________________________________ Net (take home) income: C. Employment of spouse: Name of employer: ________________________________________________ Address of employer: ______________________________________________ Employer's telephone: ______________________________________________ Length of employment: _____________________________________________ Job title or description: _____________________________________________ Net (take home) income: III. FINANCIAL STATUS A. Do you or your spouse own real property? If yes -Description: Address: _________________________________________________________ In whose name: ___________________________________________________ Estimated value $____________ Total amount owed $__________ Yes ____ No _____ Monthly $__________ or Weekly $__________ Monthly $__________ or Weekly $__________ 3 American LegalNet, Inc. www.FormsWorkFlow.com Owed to:_________________________________________________________ Annual income from property $__________ B. Do you or your spouse own any automobiles? If yes, number of automobiles owned: __________ Make __________ Make __________ Model __________ Model __________ Year __________ Year __________ Yes _____ No _____ In whose name registered: ___________________________________________ Present value $__________ Amount owed on the automobile(s) $__________ Owed to: ________________________________________________________ Monthly payment(s) $__________ C. Total amount of cash on hand, in my checking account(s) or savings account(s): $____________________ If not joint account(s) with my spouse, total amount in my spouse's checking account(s) or savings account(s): $____________________ D. In the last 12 months, have you or your spouse received any money from any of the following sources? Yes No Amount Unemployment benefits: _____ ____ ____ ____ ____ $ $ $ $ Welfare payments: _____ ADC or other governmental child support: _____ Social Security benefits: Pensions, trust funds, annuities or life insurance payment: _____ _____ ____ $ 4 American LegalNet, Inc. www.FormsWorkFlow.com Other gov't sources (exampleMedicaid benefits): Gifts or inheritances: Other sources (example-judgments in other cases or insurance proceeds): IV. OBLIGATIONS A. B. _____ _____ ____ ____ $ $ _____ ____ $ Monthly mortgage or rental payment on house or apartment $__________ Monthly mortgage payment(s) on other properties $__________ Amount of equity in other properties $__________ C. Monthly household expenses: Grocery expense Gas Electric Cable $__________ $___________ $___________ $ Phone (includes cell) $ Water Car Insurance Health Insurance Life Insurance D. $___________ $___________ $ ___________ $____________ Other monthly debts and miscellaneous expenses (examples-credit cards, medical bills, alimony, child support, student loans, tax lien or other gov't liability). To whom owed and for what reason incurred: Monthly Payment Balance Due 5 American LegalNet, Inc. www.FormsWorkFlow.com V. OTHER INFORMATION PERTINENT TO FINANCIAL STATUS: A. Have you ever filed for bankruptcy? Yes ____ No ____ B. Information regarding stocks, bonds, savings bonds, either owned individually or jointly. __________________________________________________________________ __________________________________________________________________ _________________________________________________________________ I understand that a false statement or answer to any question in this affidavit will subject me to penalties of perjury. _____________________________________ Signature