Financial Statement of Means

Document Analysis (for preparer)

Type of document: Financial Statement of Means — a sworn or certified disclosure of an individual's current financial condition used to evaluate ability to pay, support requests for relief, or support financial negotiations. It is typically completed by a single declarant and submitted to a court, tribunal, financial counterparty, or an opposing party in a dispute.

Typical sections: Identifying information; household composition; itemized income (by source and frequency); itemized assets (bank accounts, investments, real property, vehicles, business interests, other tangible assets); itemized liabilities (creditors, balances, monthly payments); monthly expenses budget; summary cash flow (total monthly income, total monthly expenses, surplus/deficit); supporting documents checklist; certification under penalty of perjury and acknowledgment of duty to update. Signature by the declarant is required. Notarization is optional depending on filing requirements.

Legal notices and certification language should be substantive: an affirmation that the information is accurate to the declarant's knowledge, that willful misrepresentation may result in penalties (perjury, contempt, sanctions), and that the declarant will supplement the statement if material changes occur. A checklist for supporting documentation is included to substantiate material entries.

FINANCIAL STATEMENT OF MEANS

A. IDENTIFICATION

Case / Reference Number:    Date of Statement:

B. HOUSEHOLD COMPOSITION

Number of adults in household:    Number of dependent children:

C. INCOME (MONTHLY BASIS)

Employment status:    Employer / Business name:

D. ASSETS (CURRENT VALUE)

Instructions: For each asset category provide the description, location/institution, current value, outstanding balance (if any), and net equity.

E. LIABILITIES (OUTSTANDING)

Provide creditor, account description, monthly payment, and outstanding balance for each liability.

F. MONTHLY EXPENSES (AVERAGE)

Enter average monthly amounts for each category.

Total monthly income:    Total monthly expenses:

Monthly surplus (income minus expenses):

G. SUPPORTING DOCUMENTS (CHECKLIST)

Please attach copies of available documents. Check all that apply:

Pay stubs (last 3 months)    Tax returns (last 2 years)    Bank statements (last 3 months)

Mortgage / loan statements    Vehicle title / registration    Other

H. CERTIFICATION, NOTICE & ACKNOWLEDGMENT

I, the undersigned, declare under penalty of perjury under the laws of the jurisdiction in which this statement is filed that the information contained in this Financial Statement of Means is true, accurate and complete to the best of my knowledge. I understand that intentionally providing false information may subject me to criminal or civil penalties including penalties for perjury and sanctions by the court.

I acknowledge that I have an ongoing duty to promptly supplement this statement if there is any material change in circumstances that affects the accuracy of the information provided herein.

I authorize the release of information necessary to verify statements made in this document to counsel, the opposing party, and the tribunal, if requested, and understand that copies of supporting documents may be retained in the court file unless otherwise ordered.

Sign Now