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THE STATE OF NEW HAMPSHIRE (State of New Hampshire)

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U.S.A. forms for State of New Hampshire

BROWSE STATE OF NEW HAMPSHIRE (NH) FORMS

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NHJB-2534-D (06/04/2008) Page 1 of 5
THE STATE OF NEW HAMPSHIRE
JUDICIAL BRANCH
http://www.courts.state.nh.us
Court Name:
Case Name:
Case Number:
(if known)
FINE PAYMENT FINANCIAL AFFIDAVIT
Name:
Address:
Telephone #: H:
W: C:
Date of Birth: Age:
Marital Status: Single Married Divorced Separated
List all dependents you currently support, including your spouse, or any other persons who reside with
you (name, relationship, date of birth, and address if different from your own).
A. C.
B. D.
1. Available Money SELF (A) SPOUSE/ADULT IN
HOUSEHOLD (B)
a. Cash on hand $ $
b. Checking account $ $
Bank name:
c. Savings account $ $
Bank name:
d. Credit cards (list the balance):
VISA:
$ ( ) $ ( )
Mastercard: $ ( ) $ ( )
Other: $ ( ) $ ( )
Available credit on credit cards $
$
e. Stocks, Bonds, Trusts, CDs, Other $ $
f. Christmas Club $ $
g. Other
$ $
TOTAL (1) $
$
(1A) (1B)
Clear Form
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Case Name:
Case Number:
FINE PAYMENT FINANCIAL AFFIDAVIT
NHJB-2534-D (06/04/2008) Page 2 of 5
2. Monthly Income SELF (A) SPOUSE/ADULT IN
(To convert weekly income to monthly, multiply by 4.333) HOUSEHOLD (B)
a. Wages - Take Home Pay $ $
b. Commissions, Bonuses, Tips $ $
c. Unemployment compensation *** $ $
d. Veteran’s Benefits *** $ $
e. Social Security, Pension, Disability, etc. *** $ $
f. Workmen’s compensation *** $ $
g. Alimony or Child Support received *** $ $
h. Interest and Dividends Income $ $
i. Public assistance/Welfare received *** $
$
j. Rental Income $
$
k. Other $ $
TOTAL (2) $ $
(2A) (2B)
A. TOTAL CASH AVAILABLE & MONTHLY INCOME: $ $
(1A & 2A) (1B & 2B)
Employment SELF (A) SPOUSE/ADULT IN
HOUSEHOLD (B)
a. Employer
b. Address
c. Phone number
d. Hours per week
Full time Part time Full time Part time
Seasonal Seasonal
If presently unemployed, state the name and address of your last employer and date(s) of employment.
a. Employer
Reason for unemployment:
b. Address
c. Phone number
d. Hours per week Full time Part time Seasonal
If you have no present income, state how you meet your expenses:
Dependency Status
Are you claimed as an exemption on anyone else’s income tax form:
Yes No
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Case Name:
Case Number:
FINE PAYMENT FINANCIAL AFFIDAVIT
NHJB-2534-D (06/04/2008) Page 3 of 5
3. Assets
1. Property (Use Fair Market Value for all amounts listed)
Do you own a house or other real estate?
Yes (If yes list) No
Market Value $
Mortgage Owed $
Mortgage Held By
Market Value $ Mortgage Owed $
Mortgage Held By
2. Motor Vehicles (autos, trucks, recreational vehicles ,boats, motorcycles, trailers, etc.)
Make
Model Year
Market Value $ Amount Owed $
Title Holder
Make Model Year
Market Value $ Amount Owed $
Title Holder
3. Do you own any other property that is jointly owned with any other person or entity?
Yes (If yes list) No
Market Value $ Mortgage Owed $
Mortgage Held by
4. Sale/Transfer
Have you sold or transferred any real estate or personal property worth $200.00 or more
within the last six months?
Yes (If yes list) No
Item
Value $
Date of Sale
Buyer’s Name
Amount Received in Sale or Transfer $
Item Value $
Date of Sale
Buyer’s Name
Amount Received in Sale or Transfer $
4. Money Owed to You
Does anyone owe you money? Yes (If yes list) No
Who owes you money?
Amount owed $
When do you expect to be paid?
Who owes you money?
Amount owed $
When do you expect to be paid?
Top of 1st Page
Case Name:
Case Number:
FINE PAYMENT FINANCIAL AFFIDAVIT
NHJB-2534-D (06/04/2008) Page 4 of 5
Are you the beneficiary of any estate or trust? Yes (if yes list) No
What is the value? $ When do you expect to receive it?
List trustee/fiduciary name and address
What is the value? $ When do you expect to receive it?
List trustee/fiduciary name and address
List income taxes paid last year: $
List income tax refund received last year: $
5. Monthly Expenses
(To convert weekly income to monthly, multiply by 4.333)
1. Housing 6. General and Personal
a. Rent/Mortgage Payment $
b. Property Tax $
c. Condo Fee $
d. Maintenance/Improvements $
e. Snow Removal/Lawn Care $
f. Other
$
2. Utilities
a. Heating Oil $
b. Wood and Coal $
c. Propane/Natural Gas $
d. Telephone $
e. Electricity $
f. Cable Television $
g. Internet $
h. Water and Sewer $
i. Trash Collection $
j. Other
$
a. Groceries/Toiletries $
b. Meals Eaten Out $
c. Tobacco/Alcohol $
d. Clothing/Shoes $
e. Hair Care/Cosmetics $
f. Pet Food and Care $
g. Church/Charities $
h. Laundry/Dry Cleaning $
i. Gifts $
j. Newspapers/Magazine $
k. Education (personal) $
l. Dues/Memberships $
m. Vacations $
n. Entertainment/Recreation $
o. Visitation Expenses $
p. Cellular Telephone(s) $
q. Other
$
3. Insurance 7. Children’s Expenses and Activities
a. Homeowner $
b. Renter $
c. Vehicle $
d. Health $
e. Dental $
f. Disability $
g. Life $
h. Other
$
a. Clothing and Shoes $
b. Diapers $
c. Day Care $
d. School Supplies $
e. School Lunches $
f. Tuition and Lessons $
g. Sports/Camps $
h. Other
$
Top of 1st Page
Case Name:
Case Number:
FINE PAYMENT FINANCIAL AFFIDAVIT
NHJB-2534-D (06/04/2008) Page 5 of 5
4. Uninsured Health Care 8. Financial
a. Medical $
b. Dental $
c. Orthodontic $
d. Eye care/Glasses/Contacts $
e. Prescription drugs $
f. Therapy/Counseling $
g. Other
$
a. Federal Income tax $
b. Social Security/Medicare $
c. Loan payments $
d. Education loan $
e. 401(k) / IRA $
f. IRA $
g. Other
$
5. Transportation 9. Other Expenses
a. Primary Vehicle Payment $
b. Other Vehicle Payments $
c. Vehicle Maintenance $
d. Gas/Oil $
e. Registration fees $
f. Other
$
(List only those payments made on a regular basis)
(DO NOT list any payments already listed elsewhere. e.g.
rent, utilities, etc)
a. $
b.
$
c.
$
d.
$
e.
$
f.
$
B. TOTAL MONTHLY EXPENSES (1-9) $
Financial Resources available : transfer figures from A & B to calculate amount:
A. Total cash and monthly income: $
-
B. Total monthly expenses: $
=
BALANCE: $
***Note: Some sources of income are protected from federal and state law from execution, levy, attachment or garnishment.
If any sources of your income fall into these categories, the court will determine whether or not you will be required to pay a
civil judgment. You may be ordered by the court to use some of this income to pay taxes, child support, restitution and
criminal fines.***
I understand that it is my responsibility to notify the court in writing of any change of my address
and/or financial circumstances.
I swear (affirm) under penalties of law that to the best of my knowledge and belief the foregoing
information is correct and complete.
Date Signature
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THE STATE OF NEW HAMPSHIRE (State of New Hampshire)

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Completed 28 May 2022

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