Affidavit Of Financial Information Mohave County

FOR CLERK'S USE ONLY Name of Person Filing: Mailing Address: City, State, Zip Code: Daytime Phone Number: Evening Phone Number: _______________________________________ ATLAS Number (if applicable):_______________________________________ Attorney Bar Number (if applicable):__________________________________ Self Petitioner Respondent Representing: (For Attorneys Only) State Bar Number: SUPERIOR COURT OF ARIZONA MOHAVE COUNTY Case No. (Name of Petitioner) AFFIDAVIT OF FINANCIAL INFORMATION AND Affidavit of : (Name of Person Whose Information is on this Affidavit) (Name of Respondent) IMPORTANT INFORMATION ABOUT THIS DOCUMENT 1. WARNING TO BOTH PARTIES: This Affidavit is an important document. You must fill out this Affidavit completely, and provide accurate information. You must provide copies of this Affidavit and all other required documents to the other party, and to the judge. If you do not do this, the court may order you to pay a fine. SIGN THIS DOCUMENT IN FRONT OF A NOTARY PUBLIC: After you fill in all the information you are asked to fill in this document, go to a Notary Public or to the Clerk of Court and sign the Affidavit in the space below. Do not sign this document until you are in front of the Notary Public or Clerk of Court. You will need picture identification when you sign. 2. State of Arizona ) County of Mohave )ss. I state to the court that I have read the following document and know of my own knowledge that the facts and financial information stated below are true and correct, and that any false information may constitute perjury by me. I also understand that if I fail to provide the required information or give misinformation, the judge might order sanctions against me, including assessment of fees for fines under Rule 11 of the Arizona Rules of Civil Procedure. DATE:_______________________________ Signature of Person Making Affidavit 3/29/2006 Page 1 of 7 American LegalNet, Inc. www.FormsWorkflow.com Case No. INSTRUCTIONS 1. Complete the entire Affidavit in black ink. If there is not enough space provided on this form, use separate sheets of paper to complete the answers and attach them to the Affidavit. Number and label any attached answers to match those on the Affidavit form. Answer every question completely! You must complete every blank. If you do not know the answer to a question or are guessing, please state that. If a question does not apply, write "NA" for "not applicable" to indicate you read the question. Round all amounts of money to the nearest dollar. 2. Answer the following statements YES or NO. If you mark NO, explain your answer on a separate piece of paper and attach the explanation to the Affidavit. YES NO 1. I listed all sources of my income. YES NO 2. I attached copies of my two (2) most recent pay stubs. YES NO 3. I attached copies of my federal income tax return for the last three (3) years, and I attached my W-2 and 1099 forms from all sources of income. 1. GENERAL INFORMATION: A. B. C. D. G. H. Name: Current Address: Date of Birth: Other Party's Date of Birth: Date of Marriage: Date of Divorce: Full names of child(ren) common to the parties (in this case), their dates of birth and Social Security Number(s): Name Date of Birth I. The name, date of birth, relationship to you and gross monthly income for each individual who lives in your household: Name Date of Birth Relationship to you Income J. Any other person for whom you contribute support: Name Age Relationship to you Where person lives 3/29/2006 Page 2 of 7 American LegalNet, Inc. www.FormsWorkflow.com Case No. 2. EMPLOYMENT INFORMATION A. Your job/occupation/profession/title: Name and address of current employer: Date current employment began: How often are you paid: Weekly ______ Every-other week _______ Monthly _______Twice a month _______ Other ________ B. C. If you are not working, why not? Previous employer name and address: Previous job/occupation/profession/title: Date previous job began: Date previous job ended: Gross monthly pay at previous job: $ Total gross income from last three (3) years' tax returns (attach sealed copies of page 1 and 2 of your federal income tax returns for the last three (3) years): Year $ Year $ Year $ Your total gross income from January 1 of this year to the date of this Affidavit (year-to-date income):$ List name of school, length of time there, year of last D. E. 3. YOUR EDUCATION/TRAINING: attendance, and degree earned: A. B. C. D. High School: College: Post-Graduate: Occupational Training: 4. ASSETS: A. B. C. D. E. F. G. H. Cash (including uncashed checks)/Traveler's check Cash in financial institutions/banks Stocks, bonds, securities Insurance policy cash surrender value Funds owed to you by others (including accounts receivable) Funds held for you by others (including inheritance(s) or trust(s)) Unpaid bonus Other $ $ $ $ $ $ $ $ $ TOTAL: 3/29/2006 Page 3 of 7 American LegalNet, Inc. www.FormsWorkflow.com Case No. 5. YOUR GROSS MONTHLY INCOME: List all income you receive from any source, whether private or governmental, taxable or not, including, but not limited to, the following. Mark each space with the correct amount or with "0" if none. List all income payable to you individually or payable jointly to you and your spouse. Multiply weekly income and deductions by 4.33. Multiply biweekly income by 2.165 to arrive at the total amount for the month. A. B. Gross salary/wages $ (attach sealed copies of your two most recent pay stubs) per hour $ per week $ per month $ Rate of Pay $ Expenses paid for by your employer: 1. Automobile $ 2. Auto expenses, such as gas, repairs, insurance $ 3. Lodging $ 4. Other (Explain) $ Commissions/Bonuses $ Tips $ Self-employment Income (See below) $ Social Security benefits $ Worker's compensation and/or disability income $ Unemployment compensation $ Gifts/Prizes $ Payments from prior spouse $ Rental income (net after expenses) $ Contributions to household living expense by others $ Other (Explain:) $ (include dividends, pensions, interest, trust income, annuities, or royalties) per year C. D. E. F. G. H. I. J. K. L. M. TOTAL: $ 6. SELF-EMPLOYMENT INCOME (if applicable): If you are self-employed, attach of a copy of the Schedule C for your business from your last tax return, and the most recent income/expense statement from your business. 7. SCHEDULE OF ALL MONTHLY EXPENSES: DO NOT LIST any expenses for the other party, or child(ren) who live with the other party, unless you are paying those expenses. U