Family Law Financial Affidavit

Florida Family Law Rules of Procedure Form 12.902(b), Family Law Financial Affidavit (Short Form) (01/15)

Instructions for Florida Family Law Rules of Procedure Form 12.902(b), Family Law Financial Affidavit (Short Form) (01/15)

When should this form be used?

This form should be used when you are involved in a family law case which requires a financial affidavit and your individual gross income is UNDER $50,000 per year unless:

(1) You are filing a simplified dissolution of marriage under rule 12.105 and both parties have waived the filing of a financial affidavit;

(2) You have no minor children, no support issues, and have filed a written settlement agreement disposing of all financial issues; or

(3) The court lacks jurisdiction to determine any financial issues.

This form should be typed or printed in black ink. After completing this form, you should sign the form before a notary public or deputy clerk. You should file the original with the clerk of the circuit court in the county where the petition was filed and keep a copy for your records.

What should I do next?

A copy of this form must be served on the other party in your case within 45 days of being served with the petition, if it is not served on him or her with your initial papers. Service must be in accordance with Florida Rule of Judicial Administration 2.516.

Where can I look for more information?

Before proceeding, you should read “General Information for Self-Represented Litigants” found at the beginning of these forms. The words that are in “bold underline” in these instructions are defined there. For further information, see Florida Family Law Rule of Procedure 12.285.

Special notes...

If you want to keep your address confidential because you are the victim of sexual battery, aggravated child abuse, aggravated stalking, harassment, aggravated battery, or domestic violence, do not enter the address, telephone, and fax information at the bottom of this form. Instead, file Request for Confidential Filing of Address, Florida Supreme Court Approved Family Law Form 12.980(h).

The affidavit must be completed using monthly income and expense amounts. If you are paid or your bills are due on a schedule which is not monthly, you must convert those amounts. Hints are provided below for making these conversions.

Conversion hints

Hourly: Hourly amount × Hours worked per week = Weekly amount; Weekly amount × 52 = Yearly amount; Yearly amount ÷ 12 = Monthly amount.

Daily: Daily amount × Days worked per week = Weekly amount; Weekly amount × 52 = Yearly amount; Yearly amount ÷ 12 = Monthly amount.

Weekly: Weekly amount × 52 = Yearly amount; Yearly amount ÷ 12 = Monthly amount.

Bi-weekly: Bi-weekly amount × 26 = Yearly amount; Yearly amount ÷ 12 = Monthly amount.

Semi-monthly: Semi-monthly amount × 2 = Monthly amount.

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida Family Law Rules of Procedure Form 12.900(a), before he or she helps you. A nonlawyer helping you fill out these forms also must put his or her name, address, and telephone number on the bottom of the last page of every form he or she helps you complete.

IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT, IN AND FOR COUNTY, FLORIDA

FAMILY LAW FINANCIAL AFFIDAVIT (SHORT FORM)

(Under $50,000 Individual Gross Annual Income)

I, , being sworn, certify that the following information is true:

My Occupation: Employed by:

Business Address:

Pay rate: $ ( ) every week ( ) every other week ( ) twice a month ( ) monthly ( ) other:

Check here if unemployed and explain on a separate sheet your efforts to find employment.

SECTION I. PRESENT MONTHLY GROSS INCOME:

All amounts must be MONTHLY. See the instructions with this form to figure out money amounts for anything that is NOT paid monthly. Attach more paper, if needed. Items included under “other” should be listed separately with separate dollar amounts.

1. $ Monthly gross salary or wages

2. Monthly bonuses, commissions, allowances, overtime, tips, and similar payments

3. Monthly business income from sources such as self-employment, partnerships, close corporations, and/or independent contracts

4. Monthly disability benefits/SSI

5. Monthly Workers’ Compensation

6. Monthly Unemployment Compensation

7. Monthly pension, retirement, or annuity payments

8. Monthly Social Security benefits

9. Monthly alimony actually received (Add 9a and 9b)

9a. From this case: $

9b. From other case(s):

10. Monthly interest and dividends

11. Monthly rental income

12. Monthly income from royalties, trusts, or estates

13. Monthly reimbursed expenses and in-kind payments to the extent that they reduce personal living expenses

14. Monthly gains derived from dealing in property (not including nonrecurring gains)

15. Any other income of a recurring nature (list source)

16.

17. $ TOTAL PRESENT MONTHLY GROSS INCOME (Add lines 1–16)

PRESENT MONTHLY DEDUCTIONS:

18. $ Monthly federal, state, and local income tax

a. Filing Status

b. Number of dependents claimed

19. Monthly FICA or self-employment taxes

20. Monthly Medicare payments

21. Monthly mandatory union dues

22. Monthly mandatory retirement payments

23. Monthly health insurance payments (including dental insurance), excluding portion paid for any minor children of this relationship

24. Monthly court-ordered child support actually paid for children from another relationship

25. Monthly court-ordered alimony actually paid (Add 25a and 25b)

25a. from this case: $

25b. from other case(s): $

26. $ TOTAL DEDUCTIONS ALLOWABLE UNDER SECTION 61.30, FLORIDA STATUTES

27. $ PRESENT NET MONTHLY INCOME (Subtract line 26 from line 17)

SECTION II. AVERAGE MONTHLY EXPENSES

Proposed/Estimated Expenses. If this is a dissolution of marriage case and your expenses as listed below do not reflect what you actually pay currently, you should write “estimate” next to each amount that is estimated.

A. HOUSEHOLD:

Mortgage or rent $

Property taxes $

Utilities $

Telephone $

Food $

Meals outside home $

Maintenance/Repairs $

Other: $

B. AUTOMOBILE

Gasoline $

Repairs $

Insurance $

C. CHILD(REN)’S EXPENSES

Day care $

Lunch money $

Clothing $

Grooming $

Gifts for holidays $

Medical/Dental (uninsured) $

Other: $

D. INSURANCE

Medical/Dental (if not listed on lines 23 or 45) $

Child(ren)’s medical/dental $

Life $

Other: $

E. OTHER EXPENSES NOT LISTED ABOVE

Clothing $

Medical/Dental (uninsured) $

Grooming $

Entertainment $

Gifts $

Religious organizations $

Miscellaneous $

Other: $

$

$

$

$

F. PAYMENTS TO CREDITORS

CREDITOR: MONTHLY PAYMENT $

$

$

$

$

$

$

$

$

$

$

28. $ TOTAL MONTHLY EXPENSES (add ALL monthly amounts in A through F above)

SUMMARY

29. $ TOTAL PRESENT MONTHLY NET INCOME (from line 27 of SECTION I. INCOME)

30. $ TOTAL MONTHLY EXPENSES (from line 28 above)

31. $ SURPLUS

32. ($ ) (DEFICIT)

SECTION III. ASSETS AND LIABILITIES

Use the nonmarital column only if this is a petition for dissolution of marriage and you believe an item is “nonmarital,” meaning it belongs to only one of you and should not be divided. You should indicate to whom you believe the item(s) or debt belongs.

A. ASSETS:

Cash (on hand) $ husband wife

Cash (in banks or credit unions) $ husband wife

Stocks, Bonds, Notes $ husband wife

Real estate: (Home) $ husband wife

(Other) $ husband wife

Automobiles $ husband wife

Other personal property $ husband wife

Retirement plans (Profit Sharing, Pension, IRA, 401(k)s, etc.) $ husband wife

Other $ husband wife

Check here if additional pages are attached.

Total Assets (add next column) $

B. LIABILITIES:

Mortgages on real estate: First mortgage on home $ husband wife

Second mortgage on home $ husband wife

Other mortgages $ husband wife

Auto loans $ husband wife

Charge/credit card accounts $ husband wife

Other $ husband wife

Check here if additional pages are attached.

Total Debts (add next column) $

C. CONTINGENT ASSETS AND LIABILITIES:

If you have any POSSIBLE assets (income potential, accrued vacation or sick leave, bonus, inheritance, etc.) or POSSIBLE liabilities (possible lawsuits, future unpaid taxes, contingent tax liabilities, debts assumed by another), you must list them here.

Contingent Assets

$ husband wife

$ husband wife

Total Contingent Assets $

Contingent Liabilities

$ husband wife

$ husband wife

Total Contingent Liabilities $

SECTION IV. CHILD SUPPORT GUIDELINES WORKSHEET

(Florida Family Law Rules of Procedure Form 12.902(e), Child Support Guidelines Worksheet, MUST be filed with the court at or prior to a hearing to establish or modify child support. This requirement cannot be waived by the parties.)

A Child Support Guidelines Worksheet IS or WILL BE filed in this case. This case involves the establishment or modification of child support.

A Child Support Guidelines Worksheet IS NOT being filed in this case. The establishment or modification of child support is not an issue in this case.

I certify that a copy of this document was [check all used]: e-mailed mailed faxed hand delivered to the person(s) listed below on

Other party or his/her attorney:

Name:

Address:

City, State, Zip:

Fax Number:

E-mail Address(es):

I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this affidavit and that the punishment for knowingly making a false statement includes fines and/or imprisonment.

STATE OF FLORIDA

COUNTY OF

Sworn to or affirmed and signed before me on by

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:

[fill in all blanks] This form was prepared for the: {choose only one} Petitioner Respondent

This form was completed with the assistance of:

name of individual

name of business

address

city state telephone number