Opinion ID: 1134727
Heading Depth: 1
Heading Rank: 13

Heading: $50,000 or more Individual Gross Annual Income)

Text: I, { full legal name } _______, being sworn, certify that the following information is true: ========================================================================================= SECTION I. INCOME ========================================================================================= 1. Date of Birth: ___________________________ 2. My occupation is: _____________________________ 3. I am currently [&check; all that apply] ___ a. Unemployed Describe your efforts to find employment, how soon you expect to be employed, and the pay you expect to receive: ___________________________________________________________ ___ b. Employed by: ______________________________________________________________________ Address: _____________________________________________________________________________ City, State, Zip code: _______________________________________________________________ Telephone Number: ____________________________________________________________________ Pay rate: $ ___ ( ) every week ( ) every other week ( ) twice a month ( ) monthly ( ) other: _______________________________________________________________ If you are expecting to become unemployed or change jobs soon, describe the change you expect and why and how it will affect your income: ___________________________________ _____________________________________________________________________________________ [] Check here if you currently have more than one job. List the information above for the second job(s) on a separate sheet and attach it to this affidavit.  c. Retired. Date of retirement: ________ Employer from whom retired: _________________________________________________________ Address: ____________________________________________________________________________ City, State, Zip code: _____________________________ Telephone Number: ______________ LAST YEAR'S GROSS INCOME: Your Income Other Party's Income ( if known ) YEAR ______ $ _________________ $ _____________________ 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.) 3. ___________ 4. Monthly disability benefits/SSI 4. ___________ 5. Monthly Workers' Compensation 5. ___________ 6. Monthly Unemployment Compensation 6. ___________ 7. Monthly pension, retirement, or annuity payments 7. ___________ 8. Monthly Social Security benefits 8. ___________ 9. Monthly alimony actually received 9a. From 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 ([] Attach sheet itemizing each item and amount.) 14. Monthly gains derived from dealing in property (not including nonrecurring 14. ___________ gains) Any other income of a recurring nature (identify source) 15. ___________________________________________________________________________ 15. ___________ 16. ___________________________________________________________________________ 16. ___________ 17. PRESENT MONTHLY GROSS INCOME (Add lines 1B16) TOTAL: 17. $ _______________ PRESENT MONTHLY DEDUCTIONS: All amounts must be MONTHLY. See the instructions with this form to figure out money amounts for anything that is NOT paid monthly. 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 61.30, FLORIDA STATUTES (Add lines 18 through 25) TOTAL: 26. $ __________ 27. PRESENT NET MONTHLY INCOME (Subtract line 26 from line 17) 27. $ __________ ===================================================================================================== SECTION EL AVERAGE MONTHLY EXPENSES ===================================================================================================== Proposed/Estimated Expenses. If this is a dissolution of marriage case anti your expenses as listed below do not reflect what you actually pay currently, you should write estimate next to each amount that is estimated. HOUSEHOLD: 1. Monthly mortgage or rent payments 1. $ ___________ 2. Monthly property taxes (if not included in mortgage) 2. ___________ 3. Monthly insurance on residence (if not included in mortgage) 3. ___________ 4. Monthly condominium maintenance fees and homeowner's association fees 4. ___________ 5. Monthly electricity 5. ___________ 6. Monthly water, garbage, and sewer 6. ___________ 7. Monthly telephone 7. ___________ 8. Monthly fuel oil or natural gas 8. ___________ 9. Monthly repairs and maintenance 9. ___________ 10. Monthly lawn care 10. ___________ 11. Monthly pool maintenance 11. ___________ 12. Monthly pest control 12. ___________ 13. Monthly misc. household 13. ___________ 14. Monthly food and home supplies 14. ___________ 15. Monthly meals outside home 15. ___________ 16. Monthly cable t.v. 16. ___________ 17. Monthly alarm service contract 17. ___________ 18. Monthly service contracts on appliances 18. ___________ 19. Monthly maid service 19. ___________ Other: 20. __________________________________________________________________________ 20. ___________ 21. __________________________________________________________________________ 21. ___________ 22. __________________________________________________________________________ 22. ___________ 23. __________________________________________________________________________ 23. ___________ 24. __________________________________________________________________________ 24. ___________ 25. SUBTOTAL (add lines 1 through 24) 25. $ ______________ AUTOMOBILE: 26. Monthly gasoline and oil 26. $ ___________ 27. Monthly repairs 27. ___________ 28. Monthly auto tags and emission testing 28. ___________ 29. Monthly insurance 29. ___________ 30. Monthly payments (lease or financing) 30. ___________ 31. Monthly rental/replacements 31. ___________ 32. Monthly alternative transportation (bus, rail, car pool, etc.) 32. ___________ 33. Monthly tolls and parking 33. ___________ 34. Other: ___________________________________________________________________ 34. ___________ 35. SUBTOTAL (add lines 26 through 34) 35. $ ___________ MONTHLY EXPENSES FOR CHILDREN COMMON TO BOTH PARTIES: 36. Monthly nursery, babysitting, or day care 36. $ ___________ 37. Monthly school tuition 37. ___________ 38. Monthly school supplies, books, and fees 38. ___________ 39. Monthly after school activities 39. ___________ 40. Monthly lunch money 40. ___________ 41. Monthly private lessons or tutoring 41. ___________ 42. Monthly allowances 42. ___________ 43. Monthly clothing and uniforms 43. ___________ 44. Monthly entertainment (movies, parties, etc.) 44. ___________ 45. Monthly health insurance 45. ___________ 46. Monthly medical, dental, prescriptions (nonreimbursed only) 46. ___________ 47. Monthly psychiatric/psychological/counselor 47. ___________ 48. Monthly orthodontic 48. ___________ 49. Monthly vitamins 49. ___________ 50. Monthly beauty parlor/barber shop 50. ___________ 51. Monthly nonprescription medication 51. ___________ 52. Monthly cosmetics, toiletries, and sundries 52. ___________ 53. Monthly gifts from child(ren) to others 53. ___________ (other children, relatives, teachers, etc.) 54. Monthly camp or summer activities 54. ___________ 55. Monthly clubs (Boy/Girl Scouts, etc.) 55. ___________ 56. Monthly access expenses (for nonresidential parent) 56. ___________ 57. Monthly miscellaneous 57. ___________ 58. SUBTOTAL (add lines 36 through 57) 58. $ _______________ MONTHLY EXPENSES FOR CHILD(REN) FROM ANOTHER RELATIONSHIP: (other than court-ordered child support) 59. _________________________________________________________________________ 59. $ ___________ 60. _________________________________________________________________________ 60. ___________ 61. _________________________________________________________________________ 61. ___________ 62. _________________________________________________________________________ 62. ___________ 63. SUBTOTAL (add lines 59 through 62) 63. $ _______________ MONTHLY INSURANCE: 64. Health insurance, excluding portion paid for any minor child(ren) of this 64. $ ___________ relationship 65. Life insurance 65. ___________ 66. Dental insurance 66. ___________ Other: 67. __________________________________________________________________________ 67. ___________ 68. __________________________________________________________________________ 68. ___________ 69. SUBTOTAL (add lines 64 through 68) 69. $ _______________ OTHER MONTHLY EXPENSES NOT LISTED ABOVE: 70. Monthly dry cleaning and laundry 70. $ ___________ 71. Monthly clothing 71. ___________ 72. Monthly medical, dental, and prescription (unreimbursed only) 72. ___________ 73. Monthly psychiatric, psychological, or counselor (unreimbursed only) 73. ___________ 74. Monthly non-prescription medications, cosmetics, toiletries, and sundries 74. ___________ 75. Monthly grooming 75. ___________ 76. Monthly gifts 76. ___________ 77. Monthly pet expenses 77. ___________ 78. Monthly club dues and membership 78. ___________ 79. Monthly sports and hobbies 79. ___________ 80. Monthly entertainment 80. ___________ 81. Monthly periodicals/books/tapes/CDs 81. ___________ 82. Monthly vacations 82. ___________ 83. Monthly religious organizations 83. ___________ 84. Monthly bank charges/credit card fees 84. ___________ 85. Monthly education expenses 85. ___________ Other: (include any usual and customary expenses not otherwise mentioned in the items listed above) 86. __________________________________________________________________________ 86. ___________ 87. __________________________________________________________________________ 87. ___________ 88. __________________________________________________________________________ 88. ___________ 89. __________________________________________________________________________ 89. ___________ 90. SUBTOTAL (add lines 70 through 89) 90. $ _______________ MONTHLY PAYMENTS TO CREDITORS: (only when payments are currently made by you on outstanding balances) NAME OF CREDITOR(s): 91. __________________________________________________________________________ 91. $ ___________ 92. __________________________________________________________________________ 92. ___________ 93. __________________________________________________________________________ 93. ___________ 94. __________________________________________________________________________ 94. ___________ 95. __________________________________________________________________________ 95. ___________ 96. __________________________________________________________________________ 96. ___________ 97. __________________________________________________________________________ 97. ___________ 98. __________________________________________________________________________ 98. ___________ 99. __________________________________________________________________________ 99. ___________ 100. __________________________________________________________________________ 100. ___________ 101. __________________________________________________________________________ 101. ___________ 102. __________________________________________________________________________ 102. ___________ 103. __________________________________________________________________________ 103. ___________ 104. SUBTOTAL (add lines 91 through 103) 104. $ _______________ 105. TOTAL MONTHLY EXPENSES: (add lines 25, 35, 58, 63, 69, 90, and 104 of Section II, Expenses) 105 $ =========== SUMMARY 106. TOTAL PRESENT MONTHLY NET INCOME (from line 27 of SECTION I. INCOME) 106 $ ___________ 107. TOTAL MONTHLY EXPENSES (from line 105 above) 107 $ ___________ 108. SURPLUS (If line 106 is more than line 107, subtract line 107 from line 108 $ ___________ 106. This is the amount of your surplus. Enter that amount here.) 109. (DEFICIT) (If line 107 is more than line 106, subtract line 106 from line 109. ($ _________) 107. This is the amount of your deficit. Enter that amount here.) ================================================================================================================== SECTION III. ASSETS AND LIABILITIES ================================================================================================================== A. ASSETS (This is where you list what you OWN.) INSTRUCTIONS: STEP 1: In column A, list a description of each separate item owned by you (and/or your spouse, if this is a petition for dissolution of marriage). Blank spaces are provided if you need to list more than one of an item. STEP 2: If this is a petition for dissolution of marriage, check the box in Column A next to any item that you are requesting the judge award to you. STEP 3: In column B, write what you believe to be the current fair market value of all items listed. STEP 4: Use column C 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 belongs. (Typically, you will only use Column C if property was owned 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 B C ASSETS: DESCRIPTION OF ITEM(S) Current Fair Nonmarital DO NOT LIST ACCOUNT NUMBERS. Market Value (&check; correct column) __________________________ &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 (money owed to you in writing) ----------------------------------------------------------------------------------------------------------------------- [] ----------------------------------------------------------------------------------------------------------------------- [] ------------------------------------------------------------------------------------------------ [] Money owed to you (not evidenced by a note) ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] Real estate: (Home) ------------------------------------------------------------------------------------------------ [] (Other) ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] Business interests ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] Automobiles ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] Boats ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [ ------------------------------------------------------------------------------------------------ [] Other vehicles ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] Retirement plans (Profit Sharing, Pension, IRA, 401(k)s, etc.) ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] Furniture & furnishings in home ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] Furniture & furnishings elsewhere ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] Collectibles ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] Jewelry ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] Life insurance (cash surrender value) ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] Sporting and entertainment (T.V., stereo, etc.) equipment ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] Other assets ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ Total Assets (add column B) $__________ ------------------------------------------------------------------------------------------------ B. LIABILITIES/DEBTS (This is where you list what you OWE.) INSTRUCTIONS: STEP 1: In column A, list a description of each separate debt owed by you (and/or your spouse, if this is a petition for dissolution of marriage). Blank spaces are provided if you need to list more than one of an item. STEP 2: If this is a petition for dissolution of marriage, check the box in Colt= A next to any debt(s) for which you believe you should be responsible. STEP 3: In column B, write what you believe to be the current amount owed for all items listed. STEP 4: Use column C only if this is a petition for dissolution of marriage and you believe an item is nonmarital, meaning the debt belongs to only one of you and should not be divided. You should indicate to whom you believe the debt belongs. (Typically, you will only use Column C if the debt was 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 B C LIABILITIES: DESCRIPTION OF ITEM(S) Current Nonmarital DO NOT LIST ACCOUNT NUMBERS. Amount Owed (&check; correct column) &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 ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] Charge/credit card accounts ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] Auto loan ------------------------------------------------------------------------------------------------ [] Auto loan ------------------------------------------------------------------------------------------------ [] Bank/Credit Union loans ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] Money you owe (not evidenced by a note) ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] Judgments ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] Other ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ Total Debts (add column B) $________ ------------------------------------------------------------------------------------------------ C. NET WORTH (excluding contingent assets and liabilities) Total Assets (enter total of Column B in Asset Table; Section A) $________ Total Liabilities (enter total of Column B in Liabilities Table; Section B) $________ TOTAL NET WORTH (Total Assets minus Total Liabilities) (excluding contingent assets and liabilities) $======== D. 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. ------------------------------------------------------------------------------------------------ A B C Contingent Assets Nonmarital Possible 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 Assets $________ ================================================================================================ A B C Contingent Liabilities Possible Nonmarital Amount (&check; correct column) ------------------------ &check; the box next to any contingent asset(s) which you Owed believe you should be responsible. husband wife ------------------------------------------------------------------------------------------------ [] $ ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ [] ------------------------------------------------------------------------------------------------ Total Contingent Liabilities $______ ------------------------------------------------------------------------------------------------ E. 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 financial affidavit was: ( ) mailed, ( ) faxed and mailed, or ( ) 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 SUPREME COURT APPROVED FAMILY LAW FORM 12.902(i), AFFIDAVIT OF CORROBORATING WITNESS