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
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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): _________________
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privacy interest of the parties.
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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?
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____________________________________________________________
____________________________________________________________
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 $__________
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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): $
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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
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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