Family Law Financial Affidavit Short Form Under $50,000 Individual Gross Annual Income Florida Legal Form

Dated:

Signature of Party,

Printed Name:

Address:

City,State,Zip:

Fax Number:

Designated E – mail Address(es):

STATE OF FLORIDA COUNTY OF

Sworn to or affirmed and signed before me on bY

NOTARY PUBLIC or DEPUTY CLERK

[Print, type, or stamp commissioned name of notary or
deputy clerk.]

Personally known

Produced identification

Type of identification produced

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}

Your full legal name:

I am the:

petitioner respondent

Other Party’s legal name:

My address:

City, state, zip:

My Phone (area code and number):

My Fax (area code and number):

My email address(es):

My Occupation:

I’m employed by:

Business Address:

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

Case No:
(leave blank if you don’t know)
Division:
(leave blank if you don’t know)

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 $

numbers only

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”.

If you are unemployed, check the box and explain on a separate sheet your efforts to find employment.

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: $ /month 25b. 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

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 (Do not include insurance deductions from your paycheck)	$
Children(ren)’s medical/dental	$
Life	$
Other	$

E. OTHER EXPENSES NOT LISTED ABOVE:
Clothing	$
Medical/Dental (uninsured)	$
Grooming	$
Entertainment	$
Gifts	$
Religious Organizations	$
Miscellaneous	$
Other	$
Other	$
Other	$
Other	$
Other	$
Other	$
Other	$
F. PAYMENTS TO CREDITORS:
Creditor	Monthly Payment
1.	$
2.	$
3.	$
4.	$
5.	$
6.	$
7.	$
8.	$
9.	$
10.	$
11.	$
12.	$

28. TOTAL MONTHLY EXPENSES

28. $

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 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 allused]“e-mailedmailedfaxedhand delivered
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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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)
Cash (on hand)	$
Cash (in banks or credit unions)	$
Stocks, Bonds, Notes	$
Real Estate (Home)	$
Real Estate (Other)	$
Automobiles	$
Other personal property	$
Retirement plans (Profit Sharing, Pension, IRA, 401(k)s, etc.)	$
Other	$
/	$
	$
	$
	$
	$
	$
check here if additional pages are attached
Total Assets	$0.00

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)
Mortgages on real estate: First mortgage on home	$
Second mortgage on home	$
Other mortgages	$
	$
Auto loans	$
	$
Charge/credit card accounts	$
	$
	$
	$
Other	$
	$
	$
	$
check here if additional pages are attached
Total Debts	$0.00

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