Affidavit of Financial Information

AFFIDAVIT OF FINANCIAL INFORMATION

Name:

Mailing Address:

City, State, Zip Code:

Daytime Phone Number:

Evening Phone Number:

Representing: Self Petitioner Respondent

State Bar Number:

ARIZONA SUPERIOR COURT, COUNTY OF COCHISE

Case No.:

Petitioner/Plaintiff:

ATLAS No.:

AFFIDAVIT OF FINANCIAL INFORMATION

Respondent:

I have read the following document and know of my own knowledge that the facts and financial information stated below are true and correct, and that any false information may constitute perjury by me. I also understand that, if I fail to provide the required information or give misinformation, the judge may order sanctions against me, including assessment of fees for fines under Rule 31, Arizona Rules of Family Law Procedure.

INSTRUCTIONS

1. Complete the entire Affidavit in black ink. If the spaces provided on this form are inadequate, use separate sheets of paper to complete the answers and attach them to the Affidavit. Answer every question completely! You must complete every blank. If you do not know the answer to a question or are guessing, please state that. If a question does not apply, write ANA for "Anot applicable" to indicate you read the question. Round all amounts of money to the nearest dollar.

2. Answer the following statements YES or NO. If you mark NO, explain your answer on a separate piece of paper and attach the explanation to the Affidavit.

YES NO 1. I listed all sources of my income.

YES NO 2. I attached copies of my two (2) most recent pay stubs.

YES NO 3. I attached copies of my federal income tax return for the last three (3) years, and I attached my W-2 and 1099 forms from all sources of income.

1. GENERAL INFORMATION:

A. Name: Date of Birth:

B. Current Address:

C. Date of Marriage: Date of Divorce:

D. Last date when you and the other party lived together:

E. Full names of child(ren) common to the parties, their dates of birth, and Social Security Number(s) (last 4 digits only):

F. Household members: names, DOB, relationship, and gross monthly income:

G. Other persons for whom you contribute support:

H. Attorney’s fees paid in this matter $ Source of funds

2. EMPLOYMENT INFORMATION

A. Your job/occupation/profession/title:

B. Name and address of current employer:

Date employment began:

How often are you paid: Weekly Every other week Monthly Twice a month Other

If you are not working, why not?

C. Previous employer name and address:

Previous job/occupation/profession/title:

Date previous job began: Date previous job ended:

Reason you left job:

Gross monthly pay at previous job: $

D. Total gross income from last three (3) years:

Year $ Year $ Year $

E. Total gross income from January 1 of this year to the date of this Affidavit: $

3. YOUR EDUCATION/TRAINING

A. High School:

B. College:

C. Post-Graduate:

D. Occupational Training:

4. YOUR GROSS MONTHLY INCOME

A. Gross salary/wages per month $

Rate of Pay $ per hour week month year

B. Expenses paid for by your employer:

1. Automobile $

2. Auto expenses, such as gas, repairs, insurance $

3. Lodging $

4. Other (Explain) $

C. Commissions/Bonuses $

D. Tips $

E. Self-employment Income $

F. Social Security benefits $

G. Worker's compensation and/or disability income $

H. Unemployment compensation $

I. Gifts/Prizes $

J. Payments from prior spouse $

K. Rental income (net after expenses) $

L. Contributions to household living expense by others $

M. Other (Explain) $

TOTAL: $

5. SELF-EMPLOYMENT INCOME

Name, address and telephone no. of business:

Type of business entity:

State and Date of incorporation:

Nature of your interest:

Nature of business:

Percent ownership:

Number of shares of stock:

Total issued and outstanding shares:

Gross sales/revenue last 12 months:

6. SCHEDULE OF ALL MONTHLY EXPENSES FOR CHILDREN

DO NOT LIST any expenses for the other party, or child(ren) who live(s) with the other party, unless you are paying those expenses.

Use a monthly average for items that vary from month to month.

If you are listing anticipated expenses, indicate this by putting an asterisk (*) next to the estimated amount.

A. HEALTH INSURANCE:

1. Total monthly cost $

2. Premium cost to insure you alone $

3. Premium cost to insure child(ren) common to the parties $

4. List all people covered by your insurance coverage:

5. Name of insurance company and Policy/Group Number:

B. DENTAL/VISION INSURANCE:

1. Total monthly cost $

2. Premium cost to insure you alone $

3. Premium cost to insure child(ren) common to the parties $

4. List all people covered by your insurance coverage:

5. Name of insurance company and Policy/Group Number:

C. UNREIMBURSED MEDICAL AND DENTAL EXPENSES:

1. Drugs and medical supplies $

2. Other $

TOTAL: $

D. CHILD CARE COSTS:

1. Total monthly child care costs $

2. Name(s) of child(ren) cared for and amount per child:

3. Name(s) and address(es) of child care provider(s):

E. EMPLOYER PRETAX PROGRAM:

Do you participate in an employer program for pretax payment of child care expenses (Cafeteria Plan)? YES NO

F. COURT ORDERED CHILD SUPPORT:

1. Court ordered current child support for child(ren) not common to the parties $

2. Amount of any arrears payment $

3. Amount per month actually paid in last 12 mos. $

4. Name(s) and relationship of minor child(ren) who you support or who live with you, but are not common to the parties.

G. COURT ORDERED SPOUSAL MAINTENANCE/SUPPORT (Alimony):

1. Court ordered spousal maintenance/support you actually pay to previous spouse: $

H. EXTRAORDINARY EXPENSES:

1. For Children (Educational Expense/Special Needs/Other): $

Explain:

2. For Self: $

Explain:

7. SCHEDULE OF ALL MONTHLY EXPENSES

DO NOT list any expenses for the other party, or children who live with the other party unless you are paying those expenses.

Use a monthly average for items that vary from month to month.

If you are listing anticipated expenses, indicate this by putting an asterisk (*) next to the estimated amount.

A. HOUSING EXPENSES:

1. House payment: a. First Mortgage $

b. Second Mortgage $

c. Homeowners Association Fee $

d. Rent $

2. Repair & upkeep $

3. Yard work/Pool/Pest Control $

4. Insurance & taxes not included in house payment $

5. Other (Explain)

TOTAL: $

B. UTILITIES:

1. Water, sewer, and garbage $

2. Electricity $

3. Gas $

4. Telephone $

5. Mobile phone/pager $

6. Internet Provider $

7. Cable/Satellite television $

8. Other (Explain)

TOTAL: $

C. FOOD:

1. Food, milk, and household supplies $

2. School lunches $

3. Meals outside home $

TOTAL: $

D. CLOTHING:

1. Clothing for you $

2. Uniforms or special work clothes $

3. Clothing for children living with you $

4. Laundry and cleaning $

TOTAL: $

E. TRANSPORTATION OR AUTOMOBILE EXPENSES:

1. Car insurance $

2. List all cars and individuals covered:

3. Car payment, if any $

4. Car repair and maintenance $

5. Gas and oil $

6. Bus fare/parking fees $

7. Other (explain)

TOTAL: $

F. MISCELLANEOUS:

1. School and school supplies $

2. School activities or fees $

3. Extracurricular activities of child(ren) $

4. Church/contributions $

5. Newspapers, magazines and books $

6. Barber and beauty shop $

7. Life insurance (beneficiary:) $

8. Disability insurance $

9. Recreation/entertainment $

10. Child(ren)'s allowance(s) $

11. Union/Professional dues $

12. Voluntary retirement contributions and savings deductions $

13. Family gifts $

14. Pet Expenses $

15. Cigarettes $

16. Alcohol $

17. Other (explain)

TOTAL: $

8. OUTSTANDING DEBTS AND ACCOUNTS

List all debts and installment payments you currently owe, but do not include items listed in Item 8 AMonthly Schedule of Expenses@. Follow the format below. Use additional paper if necessary.