Affidavit Of Financial Status

UNITED STATES DISTRICT COURT WESTERN DISTRICT OF MICHIGAN Plaintiff(s)Case No. vs. Defendant(s) AFFIDAVIT OF FINANCIAL STATUS The undersigned, with knowledge that there are criminal penalties for false statements, makes the following statements regarding marital status, residence, employment and financial status: I. MARI TAL STATUS: a. Single Married Separated Divorced b. Dependents: Wife Children, No. Others, No. II. RESIDENCE: Your address: Street City State Zip Code Telephone III. EMPLOYMENT: Are you now employed? Yes No If now employed: Name of Employer Address of Employer Employers Telephone <<<<<<<<<********>>>>>>>>>>>>> 2 How long have you been employed by present employer? Income: Monthly $ Weekly $ What is your job? Other Income IV. FINANCIAL STATUS: 1. Owner of real property: Yes No a. Description b. Address c. In whose name d. Estimated value e. Total amount owed $ To whom f. Annual income from property 2. Other property a. Automobile: Make Year b. In whose name registered c. Present value of car $ d. Amount owed $ 3. Cash on hand: $ a. Cash in banks and savings and loan associations $ b. Names and addresses of banks and associations <<<<<<<<<********>>>>>>>>>>>>> 3 4. Obligations: a. Monthly rental on house or apartment $ b. Mortgage payments on house (monthly) $ c. Other debts: To whom owed Amount $ Total monthly payments on debts: $ 5. Other information pertinent to your financial status: (Include stocks, bonds, savings bonds, interests in trusts, either owned or jointly owned, ADC, unemployment, social security, or other. Please specify which.) I declare under the penalty of perjury that the foregoing is true and correct.Dated: Signed: Plaintiff-Affiant