Fillable Florida Family Law Rules Of Procedure Form 12.902(b), Family Law Financial Affidavit (Short Form)

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Florida Family Law Rules Of Procedure Form 12.902(b), Family Law Financial Affidavit (Short Form)

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INSTRUCTIONS FOR FLORIDA FAMILY LAW RULES OF PROCEDURE FORM
12.902(b), FAMILY LAW FINANCIAL AFFIDAVIT (SHORT FORM) (01/15)
When should this form be used?
This form should be used when you are involved in a family law case which requires a financial affidavit
and your individual gross income is UNDER $50,000 per year unless:
(1) You are filing a simplified dissolution of marriage under rule 12.105 and both parties have
waived the filing of a financial affidavit;
(2) You have no minor children, no support issues, and have filed a written settlement agreement
disposing of all financial issues; or
(3) The court lacks jurisdiction to determine any financial issues.
This form should be typed or printed in black ink. After completing this form, you should sign the form
before a notary public or deputy clerk. You should file the original with the clerk of the circuit court in
the county where the petition was filed and keep a copy for your records.
What should I do next?
A copy of this form must be served on the other party in your case within 45 days of being served with
the petition, if it is not served on him or her with your initial papers. Service must be in accordance with
Florida Rule of Judicial Administration 2.516.
Where can I look for more information?
Before proceeding, you should read “General Information for Self-Represented Litigants” found at the
beginning of these forms. The words that are in “bold underline” in these instructions are defined
there. For further information, see Florida Family Law Rule of Procedure 12.285.
Special notes...
If you want to keep your address confidential because you are the victim of sexual battery, aggravated
child abuse, aggravated stalking, harassment, aggravated battery, or domestic violence, do not enter the
address, telephone, and fax information at the bottom of this form. Instead, file Request for
Confidential Filing of Address, Florida Supreme Court Approved Family Law Form 12.980(h).
The affidavit must be completed using monthly income and expense amounts. If you are paid or your
bills are due on a schedule which is not monthly, you must convert those amounts. Hints are provided
below for making these conversions.
Instructions to Florida Family Law Rules of Procedure Form 12.902(b), Family Law Financial Affidavit (Short Form)
(01/15)
Hourly - If you are paid by the hour, you may convert your income to monthly as follows:
Hourly amount x Hours worked per week = Weekly amount
Weekly amount x 52 Weeks per year = Yearly amount
Yearly amount ÷ 12 Months per year = Monthly Amount
Daily - If you are paid by the day, you may convert your income to monthly as follows:
Daily amount x Days worked per week = Weekly amount
Weekly amount x 52 Weeks per year = Yearly amount
Yearly amount ÷ 12 Months per year = Monthly Amount
Weekly - If you are paid by the week, you may convert your income to monthly as follows:
Weekly amount x 52 Weeks per year = Yearly amount
Yearly amount ÷ 12 Months per year = Monthly Amount
Bi-weekly - If you are paid every two weeks, you may convert your income to monthly as follows:
Bi-weekly amount x 26 = Yearly amount
Yearly amount ÷ 12 Months per year = Monthly Amount
Semi-monthly - If you are paid twice per month, you may convert your income to monthly as follows:
Semi-monthly amount x 2 = Monthly Amount
Expenses may be converted in the same manner.
Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida Family Law Rules
of Procedure Form 12.900(a), before he or she helps you. A nonlawyer helping you fill out these forms
also must put his or her name, address, and telephone number on the bottom of the last page of every
form he or she helps you complete.
Instructions to Florida Family Law Rules of Procedure Form 12.902(b), Family Law Financial Affidavit (Short Form)
(01/15)
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA
Case No.: ______________________
Division: _______________________
,
Petitioner,
and
,
Respondent.
FAMILY LAW FINANCIAL AFFIDAVIT (SHORT FORM)
(Under $50,000 Individual Gross Annual Income)
I, {full legal name} , being sworn, certify that the following
information is true:
My Occupation: Employed by: ___________________________
Business Address: ________________________________________________________________
Pay rate: $ ( ) every week ( ) every other week ( ) twice a month ( ) monthly
( ) other: ____________
___ Check here if unemployed and explain on a separate sheet your efforts to find employment.
SECTION I. PRESENT MONTHLY GROSS INCOME:
All amounts must be MONTHLY. See the instructions with this form to figure out money amounts for
anything that is NOT paid monthly. Attach more paper, if needed. Items included under “other” should
be listed separately with separate dollar amounts.
1. $______ Monthly gross salary or wages
2. ______ Monthly bonuses, commissions, allowances, overtime, tips, and similar payments
3. _______Monthly business income from sources such as self-employment, partnerships, close
corporations, and/or independent contracts (gross receipts minus ordinary and necessary
expenses required to produce income) (Attach sheet itemizing such income and expenses.)
4. _______Monthly disability benefits/SSI
5. _______Monthly Workers’ Compensation
6. _______Monthly Unemployment Compensation
7. _______Monthly pension, retirement, or annuity payments
8. _______Monthly Social Security benefits
9. ______ Monthly alimony actually received (Add 9a and 9b)
9a. From this case: $ _______
9b. From other case(s): _______
10. _______ Monthly interest and dividends
11. _______Monthly rental income (gross receipts minus ordinary and necessary expenses
Florida Family Law Rules of Procedure Form 12.902(b), Family Law Financial Affidavit (Short Form) (01/15)
required to produce income) (Attach sheet itemizing such income and expense items.)
12. _______ Monthly income from royalties, trusts, or estates
13. _______ Monthly reimbursed expenses and in-kind payments to the extent that they
reduce personal living expenses
14. _______ Monthly gains derived from dealing in property (not including nonrecurring gains)
15. _______ Any other income of a recurring nature (list source) _________________________
16. __________________________________________________________________________
17. $ _______ TOTAL PRESENT MONTHLY GROSS INCOME (Add lines 1–16)
PRESENT MONTHLY DEDUCTIONS:
18. $______Monthly federal, state, and local income tax (corrected for filing status and allowable
dependents and income tax liabilities)
a. Filing Status ____________
b. Number of dependents claimed _______
19. _______ Monthly FICA or self-employment taxes
20. _______ Monthly Medicare payments
21. _______ Monthly mandatory union dues
22. _______ Monthly mandatory retirement payments
23. _______ Monthly health insurance payments (including dental insurance), excluding portion
paid for any minor children of this relationship
24. _______ Monthly court-ordered child support actually paid for children from another
relationship
25. _______Monthly court-ordered alimony actually paid (Add 25a and 25b)
25a. from this case: $ _______
25b. from other case(s):$ _______
26. $_______ TOTAL DEDUCTIONS ALLOWABLE UNDER SECTION 61.30, FLORIDA STATUTES
(Add lines 18 through 25).
27. $_______ PRESENT NET MONTHLY INCOME (Subtract line 26 from line 17)
Florida Family Law Rules of Procedure Form 12.902(b), Family Law Financial Affidavit (Short Form)(01/15)
SECTION II. AVERAGE MONTHLY EXPENSES
Proposed/Estimated Expenses. If this is a dissolution of marriage case and your expenses as listed
below do not reflect what you actually pay currently, you should write “estimate” next to each amount
that is estimated.
A. HOUSEHOLD:
Mortgage or rent
Property taxes
Utilities
Telephone
Food
Meals outside home
Maintenance/Repairs
Other: __________
B. AUTOMOBILE
Gasoline
Repairs
Insurance
C. CHILD(REN)’S EXPENSES
Day care
Lunch money
Clothing
Grooming
Gifts for holidays
Medical/Dental (uninsured)
Other: ______________
D. INSURANCE
Medical/Dental (if not listed on
lines 23 or 45)
Child(ren)’s medical/dental
Life
Other:
$ _______
$_______
$_______
$ _______
$ _______
$_______
$ _______
$_______
$ _______
$_______
$_______
$ _______
$_______
$ _______
$_______
$ _______
$ _______
$ _______
$ _______
$ _______
$ _______
$ _______
E. OTHER EXPENSES NOT LISTED ABOVE
Clothing $ _______
Medical/Dental (uninsured) $_______
Grooming $ _______
Entertainment $_______
Gifts $_______
Religious organizations $_______
Miscellaneous $_______
Other: ______________ $ _______
____________________ $_______
____________________ $_______
____________________ $_______
____________________ $_______
____________________ $_______
F. PAYMENTS TO CREDITORS
CREDITOR: MONTHLY
PAYMENT
____________________ $_______
____________________ $_______
____________________ $_______
____________________ $_______
____________________ $_______
____________________ $_______
____________________ $_______
____________________ $_______
____________________ $_______
____________________ $_______
____________________ $_______
Florida Family Law Rules of Procedure Form 12.902(b), Family Law Financial Affidavit (Short Form) (01/15)
28. $_______ TOTAL MONTHLY EXPENSES (add ALL monthly amounts in A through F above)
SUMMARY
29. $_______ TOTAL PRESENT MONTHLY NET INCOME (from line 27 of SECTION I. INCOME)
30. $_______ TOTAL MONTHLY EXPENSES (from line 28 above)
31. $_______ SURPLUS (If line 29 is more than line 30, subtract line 30 from line 29. This is the amount
of your surplus. Enter that amount here.)
32. ($_______) (DEFICIT) (If line 30 is more than line 29, subtract line 29 from line 30. This is the amount
of your deficit. Enter that amount here.)
SECTION III. ASSETS AND LIABILITIES
Use the nonmarital column only if this is a petition for dissolution of marriage and you believe an item
is “nonmarital,” meaning it belongs to only one of you and should not be divided. You should indicate
to whom you believe the item(s) or debt belongs. (Typically, you will only use this column if
property/debt was owned/owed by one spouse before the marriage. See the “General Information for
Self-Represented Litigants” found at the beginning of these forms and section 61.075(1), Florida
Statutes, for definitions of “marital” and “nonmarital” assets and liabilities.)
A. ASSETS:
DESCRIPTION OF ITEM(S). List a description of each separate item
owned by you (and/or your spouse, if this is a petition for dissolution
of marriage). LIST ONLY LAST 4 DIGITS OF ACCOUNT NUMBERS. Check
the line next to any asset(s) which you are requesting the judge
award to you.
Current
Fair
Market
Value
Nonmarital
(check correct
column)
wife
Cash (on hand)
$
Cash (in banks or credit unions)
Stocks, Bonds, Notes
Real estate: (Home)
(Other)
Automobiles
Other personal property
Retirement plans (Profit Sharing, Pension, IRA, 401(k)s, etc.)
Other
____Check here if additional pages are attached.
Total Assets (add next column)
$
Florida Family Law Rules of Procedure Form 12.902(b), Family Law Financial Affidavit (Short Form)
(01/15)
B. LIABILITIES:
DESCRIPTION OF ITEM(S). List a description of each separate debt
owed by you (and/or your spouse, if this is a petition for dissolution
of marriage). LIST ONLY LAST 4 DIGITS OF ACCOUNT NUMBERS. Check
the line next to any debt(s) for which you believe you should be
responsible.
Current
Amount
Owed
Nonmarital
(check correct
column)
wife
Mortgages on real estate: First mortgage on home
$
Second mortgage on home
Other mortgages
Auto loans
Charge/credit card accounts
Other
____Check here if additional pages are attached.
Total Debts (add next column)
$
C. CONTINGENT ASSETS AND LIABILITIES:
INSTRUCTIONS: If you have any POSSIBLE assets (income potential, accrued vacation or sick leave,
bonus, inheritance, etc.) or POSSIBLE liabilities (possible lawsuits, future unpaid taxes, contingent tax
liabilities, debts assumed by another), you must list them here.
Contingent Assets
Check the line next to any contingent asset(s) which you are requesting the
judge award to you.
Possible
Value
Nonmarital
(check correct
column)
wife
$
Total Contingent Assets
$
Contingent Liabilities
Check the line next to any contingent debt(s) for which you believe you
Possible
Amount
Nonmarital
(check correct
column)
should be responsible.
Owed
wife
$
Total Contingent Liabilities
$
Florida Family Law Rules of Procedure Form 12.902(b), Family Law Financial Affidavit (Short Form)
(01/15)
________________________________
________________________________
SECTION IV. CHILD SUPPORT GUIDELINES WORKSHEET
(Florida Family Law Rules of Procedure Form 12.902(e), Child Support Guidelines Worksheet, MUST be
filed with the court at or prior to a hearing to establish or modify child support. This requirement cannot
be waived by the parties.)
[Check one only]
____ A Child Support Guidelines Worksheet IS or WILL BE filed in this case. This case involves the
establishment or modification of child support.
____ A Child Support Guidelines Worksheet IS NOT being filed in this case. The establishment or
modification of child support is not an issue in this case.
I certify that a copy of this document was [check all used]: ( ) e-mailed ( ) mailed ( ) faxed
( ) hand delivered to the person(s) listed below on {date} ________________________________.
Other party or his/her attorney:
Name: _____________________________
Address: ____________________________
City, State, Zip: _______________________
Fax Number: _________________________
E-mail Address(es): _____________________
I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this
affidavit and that the punishment for knowingly making a false statement includes fines and/or
imprisonment.
Dated:
STATE OF FLORIDA
COUNTY OF
Sworn to or affirmed and signed before me on
Signature of Party
Printed Name: ________________________________
Address: ___________________________________
City, State, Zip: ______________________________
Fax Number: ________________________________
E-mail Address(es): ____________________________
by .
NOTARY PUBLIC or DEPUTY CLERK
[Print, type, or stamp commissioned
name of notary or deputy clerk.]
____ Personally known
____ Produced identification
Type of identification produced
Florida Family Law Rules of Procedure Form 12.902(b), Family Law Financial Affidavit (Short Form)
(01/15)
IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Petitioner ( ) Respondent
This form was completed with the assistance of:
{name of individual} ,
{name of business} ___________________________________________________________________,
{address} ________________________________,
{city} ________,{state} ________ {telephone number} .
Florida Family Law Rules of Procedure Form 12.902(b), Family Law Financial Affidavit (Short Form)
(01/15)
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