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Fill and Sign the Rodeo Program Ndhsra New Salem Hs Rodeo New Salem Form

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12345678910IN DISTRICT COURT, COUNTY OF GRAND FORKS, STATE OF NORTH DAKOTA ** * Kyle L. Cvancara, ) )Civil No. Plaintiff, ) )FINANCIAL STATEMENT AND v. )AFFIDAVIT OF PLAINTIFF ) Duane A. Cvancara, ) ) Defendant.) *** ********* Kyle L. Cvancara, being duly sworn, says that affiant is the Plaintiff herein, and has read this financial statement and knows the contents thereof and that the same is true.11 1. My monthly gross income from all sources is: $928.00 12 2. My monthly take-home pay therefrom is: $850.00 13 3. My spouse’s monthly gross income from all sources is: $2,000.00 14 4. I have cash on hand: $0.00 15 5. I have on deposit in banks: $4,400.00 16 6. I have stocks and bonds in the amount of: -0- 1718 7. Other Assets and approximate value are (list):19ITEMVALUEIN POSSESSION OF:20 a. 1996 Mercury MysticunknownPlaintiff21 b. 1989 Buick Park AvenueunknownDefendant2223 8. CREDITORSUNPAID BALANCEMONTHLY PAYMENTS 24 a. Visa (Duane’s)$150.00$20.00 b. Discover (Kyle’s)$ 76.90$20.0025 c. Target (Kyle’s)$ 80.00$20.00 d. Mastercard (Kyle’s)$ 150.00$20.0026 e. First Bank (Kyle’s car)$10,407.84$216.58 f. Altru$500.00$75.0027 g. Dr. Kelly$ 140.00$50.0028TOTAL$11,504.74$421.58 12 9.My necessary monthly expenses to support myself and child are as follows 3 Rent (includes water and electric) $380.00 Life Insurance 15.00 4 Medical Insurance 103.00 Renter’s Insurance 10.00 5 Car Insurance 50.00 Transportation (gas, oil, repairs) 75.00 6 Daycare (if applicable) [$194/month for summer] 25.00 7 Unreimbursed Medical & Dental Expenses 50.00 Entertainment & Recreation 50.00 8 Utilities -0- Water -0- 9 Telephone 50.00 Cable 30.00 10Food 150.00 Clothing 100.00 11Laundry & Dry Cleaning 20.00 Other:12Personal allowance 50.00 Other (identify) Mastercard 20.00 13Discover 20.00 Target 20.00 14Attorney fees 200.00 Car payment 217.00 15TOTAL $1635.00 16171819202122232425262728Dated this _____ day of August, 1998. ___________________________________________ Kyle L. Cvancara, Affiant Subscribed and sworn to before me this _____ day of August, 1998. ___________________________________________Notary PublicState of North Dakota

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