Fillable IN THE UNITED STATES DISTRICT COURT FOR THE (US Courts)

Fill Online, Printable, Fillable, Blank IN THE UNITED STATES DISTRICT COURT FOR THE (US Courts) Form

Use Fill to complete blank online US COURTS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

IN THE UNITED STATES DISTRICT COURT FOR THE (US Courts)

On average this form takes 35 minutes to complete

The IN THE UNITED STATES DISTRICT COURT FOR THE (US Courts) form is 6 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 138 other fields

Country of origin: US
File type: PDF

BROWSE US COURTS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Revised 12/2012
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF KANSAS
_________________________________ )
)
Plaintiff(s), )
)
vs. ) Case No. _________________________
)
________________________________ )
)
Defendant(s). )
AFFIDAVIT OF FINANCIAL STATUS
1
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): _________________
1
Access to this document is restricted pursuant to the court=s policy to protect the personal
privacy interest of the parties.
Reset Form
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 _____
If employer provides health insurance, what kind?
3
____________________________________________________________
____________________________________________________________
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: Monthly $__________ or Weekly $__________
C. Employment of spouse:
Name of employer: ________________________________________________
Address of employer: ______________________________________________
Employer's telephone: ______________________________________________
Length of employment: _____________________________________________
Job title or description: _____________________________________________
Net (take home) income: Monthly $__________ or Weekly $__________
III. FINANCIAL STATUS
A. Do you or your spouse own real property? Yes ____ No _____
If yes -Description:
Address: _________________________________________________________
In whose name: ___________________________________________________
Estimated value $____________
Total amount owed $__________
Owed to:_________________________________________________________
Annual income from property $__________
4
B. Do you or your spouse own any automobiles? Yes _____ No _____
If yes, number of automobiles owned: __________
Make __________ Model __________ Year __________
Make __________ Model __________ Year __________
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: $
Other gov=t sources (example-
Medicaid benefits): $
5
Gifts or inheritances: $
Other sources (example-judgments in
other cases or insurance proceeds): $
IV. OBLIGATIONS
A. Monthly mortgage or rental payment on house or apartment $__________
B. 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 Balance Due
Payment
6
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 of Plaintiff
_____________________________________
Name (Print or Type)
_____________________________________
_____________________________________
Address
_____________________________________
City State Zip Code
_____________________________________
Telephone
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

IN THE UNITED STATES DISTRICT COURT FOR THE (US Courts)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 7 April 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document