State of Affidavit
County of Affidavit
Name of Wife
Address of Wife
City of Wife
State of Wife
Zip of Wife
Phone of Wife
Occupation
Employed by
Address of Employer:
Pay Period:
Next Pay Day:
Rate of Pay:
Gross Monthly Income Salary or Wages
Minus Social Security
Minus Income Tax
Insurance /Month
Credit Union/Month
Union Dues/Month
Other Dues/Month
Net Monthly Salary, Wages ***
Commissions, Bonuses, etc./Month
Unemployment, Welfare, etc./Month
Dividends, Interest, etc./Month
Business Income/Month
Rents, Royalties/Month
Other Monthly Income/Month
Total Average Monthly Income: ***
Mo.Exp.Mortgage or Rent
Mo.Exp.Property Taxes
Mo.Exp.Homeowners Insurance
Mo.Exp.Electricity
Mo.Exp.Water, Garbage, Sewer
Mo.Exp.Cable Television
Mo.Exp.Telephone
Mo.Exp.Fuel Oil and Natural Gas
Mo.Exp.Cleaning and Laundry
Mo.Exp.Repairs and Maintenance
Mo.Exp.Pest Control
Mo.Exp.Housewares
Mo.Exp.Groceries
Mo.Exp.Meals Outside of Home
Mo.Exp.Clothing
Mo.Exp.Medical, Dental, Prescriptions
Mo.Exp.Education
Mo.Exp.Day Care/Baby Sitter
Mo.Exp.Entertainment
Mo.Exp.Gifts or Donations
Mo.Exp.Vacation Expenses
Mo.Exp.Public Transportation
Mo.Exp.Car Gasoline and Oil
Mo.Exp.Car Repairs
Mo.Exp.Car License
Mo.Exp.Car Insurance
Mo.Exp.Car Payments
Insur.Health
Insur.Disability
Insur.Life
Insur.Other
Other Exp.(1)
Other Exp.(2)
Other Exp.(3)
Creditor (1)
Monthly Payment TO (1)
Creditor (2)
Monthly Payment TO (2)
Creditor (3)
Monthly Payment TO (3)
Creditor (4)
Monthly Payment TO (4)
Creditor (5)
Monthly Payment TO (5)
Creditor (6)
Monthly Payment TO (6)
Creditor (7)
Monthly Payment TO (7)
Total Average Monthly Expenses: ***
Assets: Cash
Assets: Stocks
Assets: Bonds
Assets: Real Estate
Assets: Automobiles
Assets: Contents Home/Apartment
Assets: Jewelry
Assets: Other: (1)
Assets: VAL (1)
Assets: Other (2)
Assets: VAL (2)
Assets: Other (3)
Assets: VAL (3)
Total Assets: ***
Creditor (1)
Balance due (1)
Creditor (2)
Balance due (2)
Creditor (3)
Balance due (3)
Creditor (4)
Balance due (4)
Creditor (5)
Balance due (5)
Creditor (6)
Balance due (6)
Total Liabilities: ***