IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA
Petitioner,
and
Respondent.
Employment Information
If you have a different pay period than the choices given below, or your pay varies (for instance if you have more than one job and different pay periods), estimate your total average pay as closely as possible and convert it to a monthly pay amount. Enter it here as monthly.
If you receive a regular paycheck from an employer, then choose your pay rate and pay period below, and the income table will calculate monthly totals for you, based on your pay stub deductions. However, if you have multiple jobs with different pay periods, are self-employed, retired, etc, choose “monthly” here so that no further calculations will be done on your entries in the income table.
Pay rate $
Your Gross Monthly pay is $
If this doesn’t seem right, please double-check your entry, or calculate your monthly gross wages manually and enter it above as “Monthly”.
SECTION I. PRESENT MONTHLY GROSS INCOME
Attach extra sheets to your printed form, if needed to cover extra items and
descriptions. Items included under “other” should be listed separately with
separate dollar amounts. Where you calculate amounts, make sure and use MONTHLY
amounts for all the following sections, unless otherwise noted.
The online form makes conversions between other pay periods to monthy, as far as
possible.
| 1. Monthly gross salary or wages | 1. $ 0 |
| 2. Monthly bonuses, commission, allowances, overtime, tips and similar payments | 2. $ |
| 3. Monthly business income from sources such as self-employment, partnerships, close corporations, and/or independent contracts (gross receipts minus ordinary and necessary expenses required to produce income) (Attach sheet itemizing such income and expenses.) | 3. $ |
| 4. Monthly disability benefits/SSI received | 4. $ |
| 5. Monthly Workers’ Compensation received | 5. $ |
| 6. Monthly Unemployment Compensation received | 6. $ |
| 7. Monthly pension, retirement, or annuity payments received | 7. $ |
| 8. Monthly Social Security Benefits received | 8. $ |
| 9. Monthly Alimony payment actually received 9a. From this case: $
9b. From other case(s): $ |
9. $ 0 |
| 10. Monthly interest and dividends received | 10. $ |
| 11. Monthly rental income (gross receipts minus ordinary and necessary expenses required to produce income) (Attach sheet itemizing such income and expense items.) |
11. $ |
| 12. Monthly income from royalties, trusts, or estates | 12. $ |
| 13. Monthly reimbursed expenses and in-kind payments to the extent that they reduce personal living expenses | 13. $ |
| 14. Monthly gains derived from dealing in property (not including nonrecurring gains) | 14. $ |
| 15. Any other income of a recurring nature (list source) | 15. $ |
| 16. Any other income of a recurring nature (list source) | 16. $ |
| 17. PRESENT MONTHLY GROSS INCOME TOTAL: | 17. $ 0.00 |
SECTION I. PRESENT MONTHLY DEDUCTIONS
| 18. Federal, state and local income tax (corrected for filing status and allowable dependents and income tax liabilities) Add up your adjusted tax totals from your current IRS, State and local returns. Do not convert to monthly $ a. Filing Status b. Number of dependents claimed |
18. $ 0.00 /month |
| 19. FICA or self-employment taxes Amount listed on your most recent pay stub: |
19. $ 0 /month |
| 20. Medicare payments Amount listed on your most recent pay stub: |
20. $ /month |
| 21. Mandatory union dues Amount listed on your most recent pay stub: |
21. $ /month |
| 22. Mandatory retirement payments Amount listed on your most recent pay stub: |
22. $ /month |
| 23. Employer health insurance payments, including dental insurance. Exclude portion paid for any minor children of this relationship, or insurance not provided by your employer. Amount listed on your most recent pay stub: |
23. $ /month |
| 24. Monthly court-ordered child support actually paid for children from another relationship |
24. $ /month |
| 25. Monthly court-ordered alimony actually paid 25a. From this case: $ /month25b. From other case(s): $ /month |
25. $ 0 /month |
26. TOTAL DEDUCTIONS ALLOWABLE UNDER SECTION 61.30, FLORIDA STATUTES (Add lines 18 through 25): |
26. $ |
| PRESENT NET MONTHLY INCOME : | 26. $ |
SECTION II. AVERAGE MONTHLY EXPENSES
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SUMMARY
| 29. TOTAL PRESENT MONTHLY NET INCOME (from line 27 of SECTION I. INCOME) |
29. $ 0 |
| 30. TOTAL MONTHLY EXPENSES (from line 28 above) |
30. $ 0.00 |
| 31. SURPLUS (if line 29 is more than line 30, subtract line 30 from line 29. This is the amount of your surplus. Enter that amount here.) |
31. $ |
| 32. (DEFICIT) (if line 29 is less than line 30, subtract line 29 from line 30. This is the amount of your deficit. Enter that amount here.) |
$ () |
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. (Typically, you will only use this column if property/debt was owned/owed by one spouse before the marriage. See the “General Information for Self-Represented Litigants” found at the beginning of these forms and section 61.075(1), Florida Statutes, for definitions of “marital” and “nonmarital” assets and liabilities.)
A. ASSETS:
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| Description of Items. List a description of each separate item owned by you (and/or your spouse, if this is a petition for dissolution of marriage). LIST ONLY LAST 4 DIGITS OF ACCOUNT NUMBERS. Check the box next to any asset(s) which you are requesting the judge award to you. |
Current Fair Market Value | husband (Don’t check this column except for separate, non-marital items) | wife (Don’t check this column except for separate, non-marital items) |
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| Total Assets | $0.00 |
B. LIABILITIES (DEBTS):
| DESCRIPTION OF ITEM(S). List a description of each separate debt owed by you (and/or your spouse, if this is a petition for dissolution of marriage). LIST ONLY LAST 4 DIGITS OF ACCOUNT NUMBERS. Check the line next to any debt(s) for which you believe you should be responsible. | Current Amount Owed | husband (Don’t check this column except for separate, non-marital items) | wife (Don’t check this column except for separate, non-marital items) |
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| Total Debts | $0.00 | ||
C. CONTINGENT ASSETS AND LIABILITIES:
INSTRUCTIONS: 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 AssetsCheck the box next to any asset(s) which you are requesting the judge award to you. |
Possible Value | husband(Don’t check this column except for separate, non-marital items) | wife(Don’t check this column except for separate, non-marital items) |
| $ | |||
| $ | |||
| Total contingent Assets | $0.00 |
Contingent LiabilitiesCheck the box next to any asset(s) which you believe you should be responsible. |
Possible Amount Owed | husband(Don’t check this column except for separate, non-marital items) | (Don’t check this column except for separate, non-marital items) wife |
| $ | |||
| $ | |||
| Total contingent Liabilities | $0.00 |
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.)
I certify that a copy of this document was [check allused]“
to the person(s) listed below on {date}.
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.
IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW: [fill in all blanks]
full legal name of Non-Lawyer
Business
Street:
City:
State:
Phone:
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