Opinion ID: 1134727
Heading Depth: 1
Heading Rank: 7

Heading: Under $50,000 Individual Gross Annual Income)

Text: I, { full legal name } _______, 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 1. $ _________ 2. Monthly bonuses, commissions, 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.) 4. Monthly disability benefits/SSI 3. _________ 5. Monthly Workers' Compensation 4. _________ 6. Monthly Unemployment Compensation 5. _________ 7. Monthly pension, retirement, or annuity payments 6. _________ 8. Monthly Social Security benefits 7. _________ 9. Monthly alimony actually received 8. _________ 9a. V-om this case: $ __________ 9b. From other case(s): __________ Add 9a and 9b 9. _________ 10. Monthly interest and dividends 10. _________ 11. Monthly rental income (gross receipts minus ordinary and necessary expenses 11. _________ required to produce income) ([] Attach sheet itemizing such income and expense items.) 12. Monthly income from royalties, trusts, or estates 12. _________ 13. Monthly reimbursed expenses and in-kind payments to the extent that they 13. _________ reduce personal living expenses 14. Monthly gains derived from dealing in property (not including nonrecurring 14. _________ gains) 15. Any other income of a recurring nature (list source) ____________________ 15. _________ 16. __________________________________________________________________________ 16. _________ 17. PRESENT MONTHLY GROSS INCOME (Add lines 1-16) TOTAL: 17. $____________ PRESENT MONTHLY DEDUCTIONS: 18. Monthly federal, state, and local income tax (corrected for filing status and allowable dependents and income tax liabilities) a. Filing Status _____________________ b. Number of dependents claimed _______________ 18. $_________ 19. Monthly FICA or self-employment taxes 19. _________ 20. Monthly Medicare payments 20. _________ 21. Monthly mandatory union dues 21. _________ 22. Monthly mandatory retirement payments 22. _________ 23. Monthly health insurance payments (including dental insurance), excluding 23. _________ portion paid for any minor children of this relationship 24. Monthly court-ordered child support actually paid for children from another 24. _________ relationship 25. Monthly court-ordered alimony actually paid 25a. from this case: $_________________ 25b. from other case(s): _________________ Add 25a and 25b 25. _________ 26. TOTAL DEDUCTIONS ALLOWABLE UNDER SECTION TOTAL: 26. $_________ 61.30, FLORIDA STATUTES (Add lines 18 through 25) PRESENT NET MONTHLY INCOME (Subtract line 26 from line 17) 27. $_________ _________ SECTION II. AVERAGE MONTHLY EXPENSES A. HOUSEHOLD: E. OTHER EXPENSES NOT LISTED ABOVE Mortgage or rent $________________ Clothing $______ Property taxes $________________ Medical/Dental (uninsured) $______ Utilities $________________ Grooming $______ Telephone $________________ Entertainment $______ Food $________________ Gifts $______ Meals outside home $________________ Religious organizations $______ Maintenance/Repairs $________________ Miscellaneous $______ Other: ________________ $________________ Other: __________________ $______ _________________________ $______ B. AUTOMOBILE _________________________ $______ Gasoline $________________ _________________________ $______ Repairs $________________ _________________________ $______ Insurance $________________ _________________________ $______ _________________________ $______ C. CHILD(REN)'S EXPENSES Day care $________________ F. PAYMENTS TO CREDITORS Lunch money $________________ MONTHLY Clothing $________________ CREDITOR: PAYMENT Grooming $________________ _______________________ $______ Gifts for holidays $________________ _______________________ $______ Medical/Dental (uninsured) _________________ _______________________ $______ Other: ________________ $________________ _______________________ $______ _______________________ $______ D. INSURANCE _______________________ $______ Medical/Dental $________________ _______________________ $______ Child(ren)'s medical/dental $________________ _______________________ $______ Life $________________ _______________________ $______ Other: ________________ $________________ _______________________ $______ _______________________ $______ 28. TOTAL MONTHLY EXPENSES (add ALL monthly amounts in A through F above) 28. $_______ SUMMARY 29. TOTAL PRESENT MONTHLY NET INCOME (from line 27 of SECTION I. INCOME) 29. $_________ 30. TOTAL MONTHLY EXPENSES (from line 28 above) 30. $_________ 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. $_________ 32. (DEFICIT) (If line 30 is more than line 29, subtract line 29 from line 30. This is the amount of your deficit. Enter that amount here.) 32. ($_______) 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: --------------------------------------------------------------------------------------------- DESCRIPTION OF ITEM(S). List a description of Current Fair Nonmarital each separate item owned by you (and/or your spouse, if Market Value (&check; correct column) this is a petition for dissolution of marriage). ____________________ DO NOT LIST ACCOUNT NUMBERS. &check; the box next to any asset(s) which you are requesting the judge award to you. husband wife _____________________________________________________________________________________________ [] Cash (on hand) $ _____________________________________________________________________________________________ [] Cash (in banks or credit unions) _____________________________________________________________________________________________ [] Stocks, Bonds, Notes _____________________________________________________________________________________________ [] Real estate: (Home) _____________________________________________________________________________________________ [] (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 (add next column) $ _______ _____________________________________________________________________________________________ B. LIABILITIES: ___________________________________________________________________________________________________ DESCRIPTION OF ITEM(S). List a description of Current Nonmarital each separate debt owed by you (and/or your spouse, Amount Owed (&check; correct column) if this is a petition for dissolution of marriage). _______________________ DO NOT LIST ACCOUNT NUMBERS. &check; the box next to any debt(s) for which you believe you should be responsible. husband wife ___________________________________________________________________________________________________ [] 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 (add next column) $ ________ ___________________________________________________________________________________________________ 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 Assets Possible Nonmarital Value (&check; correct column) ____________________________________ &check; the box next to any contingent asset(s) which you are requesting the judge award to you. husband wife ___________________________________________________________________________________________________ [] $ ___________________________________________________________________________________________________ [] ___________________________________________________________________________________________________ Total Contingent Liabilities $ _________ =================================================================================================== Possible Nonmarital Contingent Liabilities Amount (&check; correct column) ___________________________________ &check; the box next to any contingent debt(s) for which you Owed husband wife believe you should be responsible. ___________________________________________________________________________________________________ [] $ ___________________________________________________________________________________________________ [] ___________________________________________________________________________________________________ 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.) [&check; one only] ___ 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; one only] ( ) mailed ( ) faxed and mailed ( ) hand delivered to the person(s) listed below on { date } ________. Other party or his/her attorney: Name: ______________ Address: _____________ City, State, Zip: _____________ Fax Number: _______________ 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. Dated: _____ __________ Signature of Party Printed Name. Address. City, State, Zip. Telephone Number Fax Number. 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] I, { full legal name and trade name of nonlawyer } ________, a nonlawyer, located at { street } ________, { city } _______, { state } _______, { phone } ______, helped { name } ___________, who is the [&check; one only] ___ petitioner or ___ respondent, fill out this form. INSTRUCTIONS FOR FLORIDA FAMILY LAW RULE OF PROCEDURE FORM 12.902(c), FAMILY LAW FINANCIAL AFFIDAVIT