Fine Payment Financial Affidavit {NHJB-2534-D}

THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) FINE PAYMENT FINANCIAL AFFIDAVIT Name: Address: Date of Birth: Marital Status: Single Telephone #: H: W: C: Age: Married Divorced Separated List all dependents you currently support, including your spouse, or any other persons who reside with you (name, relationship, date of birth, and address if different from your own). A. B. C. D. SELF (A) $ $ $ 1. Available Money a. Cash on hand b. Checking account Bank name: c. Savings account Bank name: d. Credit cards (list the balance): VISA: Mastercard: Other: Available credit on credit cards e. Stocks, Bonds, Trusts, CDs, Other f. Christmas Club g. Other TOTAL (1) SPOUSE/ADULT IN HOUSEHOLD (B) $ $ $ $ $ $ $ $ $ $ $ (1A) $ $ $ $ $ $ $ $ (1B) NHJB-2534-D(06/09/2008) Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: FINE PAYMENT FINANCIAL AFFIDAVIT 2. Monthly Income (To convert weekly income to monthly, multiply by 4.333) SELF (A) $ $ $ $ $ $ $ $ $ $ $ $ (2A) $ (1A & 2A) SPOUSE/ADULT IN HOUSEHOLD (B) $ $ $ $ $ $ $ $ $ $ $ $ (2B) $ (1B & 2B) a. Wages - Take Home Pay b. Commissions, Bonuses, Tips c. Unemployment compensation*** d. Veteran's Benefits *** e. Social Security, Pension, Disability, etc.*** f. Workmen's compensation *** g. Alimony or Child Support received*** h. Interest and Dividends Income i. Public assistance/Welfare received*** j. Rental Income k. Other TOTAL (2) A. TOTAL CASH AVAILABLE & MONTHLY INCOME: Employment a. Employer b. Address c. Phone number d. Hours per week SELF (A) SPOUSE/ADULT IN HOUSEHOLD (B) Full time Seasonal Part time Full time Seasonal Part time If presently unemployed, state the name and address of your last employer and date(s) of employment. a. Employer b. Address c. Phone number d. Hours per week Full time Part time Seasonal If you have no present income, state how you meet your expenses: Reason for unemployment: Dependency Status Are you claimed as an exemption on anyone else's income tax form: NHJB-2534-D(06/09/2008) Page 2 of 5 Yes No American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: FINE PAYMENT FINANCIAL AFFIDAVIT 3. Assets 1. Property (Use Fair Market Value for all amounts listed) Do you own a house or other real estate? Market Value Mortgage Held By Market Value Mortgage Held By 2. Motor Vehicles (autos, trucks, recreational vehicles ,boats, motorcycles, trailers, etc.) Make Market Value Title Holder Make Market Value Title Holder 3. Do you own any other property that is jointly owned with any other person or entity? Yes (If yes list) Market Value Mortgage Held by 4. Sale/Transfer Have you sold or transferred any real estate or personal property worth $200.00 or more within the last six months? Yes (If yes list) No Item Date of Sale Amount Received in Sale or Transfer $ Item Date of Sale Amount Received in Sale or Transfer $ Yes (If yes list) Mortgage Owed $ Mortgage Owed $ No $ $ Model $ Model $ Amount Owed $ Year Amount Owed $ Year No $ Mortgage Owed $ Value $ Buyer's Name Value $ Buyer's Name 4. Money Owed to You Does anyone owe you money? Who owes you money? When do you expect to be paid? Who owes you money? When do you expect to be paid? NHJB-2534-D(06/09/2008) Page 3 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Yes (If yes list) No Amount owed $ Amount owed $ Case Name: Case Number: FINE PAYMENT FINANCIAL AFFIDAVIT Are you the beneficiary of any estate or trust? What is the value? $ What is the value? $ Yes (if yes list) No When do you expect to receive it? When do you expect to receive it? List trustee/fiduciary name and address List trustee/fiduciary name and address List income taxes paid last year: List income tax refund received last year: $ $ 5. Monthly Expenses (To convert weekly income to monthly, multiply by 4.333) 1. Housing a. Rent/Mortgage Payment b. Property Tax c. Condo Fee d. Maintenance/Improvements e. Snow Removal/Lawn Care f. Other 2. Utilities a. Heating Oil b. Wood and Coal c. Propane/Natural Gas d. Telephone e. Electricity f. Cable Television g. Internet h. Water and Sewer i. Trash Collection j. Other 3. Insurance a. Homeowner b. Renter c. Vehicle d. Health e. Dental f. Disability g. Life h. Other 6. General and Personal $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ a. Groceries/Toiletries b. Meals Eaten Out c. Tobacco/Alcohol d. Clothing/Shoes e. Hair Care/Cosmetics f. Pet Food and Care g. Church/Charities h. Laundry/Dry Cleaning i. Gifts j. Newspapers/Magazine k. Education (personal) l. Dues/Memberships m. Vacations n. Entertainment/Recreation o. Visitation Expenses p. Cellular Telephone(s) $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ q. Other 7. Children's Expenses and Activities a. Clothing and Shoes $ b. Diapers c. Day Care d. School Supplies e. School Lunches f. Tuition and Lessons g. Sports/Camps h. Other $ $ $ $ $ $ $ NHJB-2534-D(06/09/2008) Page 4 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: FINE PAYMENT FINANCIAL AFFIDAVIT 4. Uninsured Health Care a. Medical b. Dental c. Orthodontic d. Eye care/Glasses/Contacts e. Prescription drugs f. Therapy/Counseling g. Other 5. Transportation a. Primary Vehicle Payment b. Other Vehicle Payments c. Vehicle Maintenance d. Gas/Oil e. Registration fees f. Other $ $ $ $ $ $ $ 8. Financial a. Federal Income tax b. Social Security/Medicare c. Loan payments d. Education loan e. 401(k)IRA f. IRA g. Other 9. Other Expenses $ $ $ $ $ $ $ $ $ $ $ $ $ (List only those payments made on a regular basis) (DO NOT list any payments already listed elsewhere. e.g. rent, utilities, etc) a. b. c. d. e. f. $ $ $ $ $ $ B. TOTAL MONTHLY EXPENSES (1-9) Financial Resources available : A. B. $ transfer figures from A & B to calculate amount: $ $ = $ Total cash and monthly income: Total monthly expenses: BALANCE: ***Note: Some sources of income are protected from federal and state law from execution, levy, attachment or garnishment. If any sources of your income fall into these categories, the court will determine whether or not you will be required to pay a civil judgment. You may be ordered by the court to use some of this income to pay taxes, child support, restitution and criminal fines.*** I understand that it is my responsibility to notify the court in writing of any change of my address and/or financial circumstances. I swear (affirm) under penalties of law that to the best of my knowledge and belief the foregoing information is correct and