ATTACHMENT TO FINANCIAL STATEMENT (SIMPLIFIED)
_______________________________________________________________________________________________________________________________________________________________________________________________
Please answer the following questions:
My age is:_____________
I work about______________ hours a week.
My average monthly pay from work is: $_________.
(For average monthly pay, add up all the pay you received in the last 12 months and divide the total by 12.)
How much money total do you have in your checking accounts, Total
savings, credit union or other deposit accounts? $_________.
Installment Payments
(like credit cards, car payments, medical payments)
Paid to For Amount Balance Date of last payment
$ $
$ $
$ $
$ $
$ $
$ $
I promise everything is true, under penalty of perjury
Date: _____________________ Signature: ___________________________________
Optional Form
VN237 (01/11)
ATTACHMENT TO FINANCIAL STATEMENT
(SIMPLIFIED)
Case Number
_______________________
