Family Law Financial Affidavit (Short Form) — Property & Finances

a. General Information

My Occupation: Enter your job title or the kind of work you do. Employed by: Write the name of the company or person you work for. Business Address: Enter the full street address of your workplace. Pay rate: $ Write the dollar amount you get paid each pay period before taxes. every week Check this box if you get paid one time each week. every other week Check this box if you get paid once every two weeks. twice a month Check this box if you get paid two times each month. monthly Check this box if you get paid one time each month. other: If your pay schedule is different from the choices above, describe it here. Check here if unemployed and explain on a separate sheet your efforts to find employment. Check this box if you do not have a job. You will need to explain how you are looking for work on a separate sheet. 1. $____ Monthly gross salary or wages Write how much money you earn each month from your job before any taxes are taken out. 2. ____ Monthly bonuses, commissions, allowances, overtime, tips, and similar payments Write the monthly total of any extra pay like bonuses, tips, overtime, or commissions. 3. ____ Monthly business income from sources such as self-employment, partnerships, close corporations, and/or independent contracts Write your monthly income from your own business after subtracting normal business costs. Attach a sheet showing the details. 4. ____ Monthly disability benefits/SSI Write how much you get each month in disability or SSI payments. 5. ____ Monthly Workers' Compensation Write how much you get each month from Workers' Compensation. 6. ____ Monthly Unemployment Compensation Write how much you get each month in unemployment payments. 7. ____ Monthly pension, retirement, or annuity payments Write how much you get each month from a pension, retirement, or annuity. 8. ____ Monthly Social Security benefits Write how much you get each month in Social Security benefits. 9. ____ Monthly alimony actually received (Add 9a and 9b) Write the total monthly alimony you receive. Add the amounts from 9a and 9b together. 9a. From this case: $ Write the monthly alimony you get from this specific case. 9b. From other case(s): $ Write the monthly alimony you get from any other cases. Monthly interest and dividends Write the average amount of money you get each month from interest on bank accounts or dividends from stocks and investments. Monthly rental income (gross receipts minus ordinary and necessary expenses required to produce income) (Attach sheet itemizing such income and expense items.) Write how much you earn each month from renting out property, after subtracting the normal costs to keep it running. Attach a sheet showing the income and expenses. Monthly income from royalties, trusts, or estates Write the monthly amount you receive from royalties, trusts, or money left to you in an estate. Monthly reimbursed expenses and in-kind payments to the extent that they reduce personal living expenses Write the monthly value of payments or items you get from work or others that pay for things you would otherwise pay for yourself, like a company car or free housing. Monthly gains derived from dealing in property (not including nonrecurring gains) Write the monthly money you make from buying and selling property as a regular activity. Do not include one-time sales. Any other income of a recurring nature (list source) Write the monthly amount of any other income you get on a regular basis that wasn't listed above. Any other income of a recurring nature (list source) Name where this other regular income comes from, such as a side job or benefit. 16. Use this blank line to list any extra source of monthly income not already covered. Leave it blank if you have none. TOTAL PRESENT MONTHLY GROSS INCOME (Add lines 1–16) Add up all the monthly income amounts from lines 1 through 16 and write the total here. Monthly federal, state, and local income tax (corrected for filing status and allowable dependents and income tax liabilities) Write how much you pay each month in federal, state, and local income taxes, based on your filing status and dependents. Filing Status Write how you file your taxes, such as single, married filing jointly, or head of household. Number of dependents claimed Write how many dependents you claim on your taxes. Monthly FICA or self-employment taxes Write how much you pay each month for Social Security taxes (FICA) or self-employment taxes. Monthly Medicare payments Write the amount taken out of your pay each month for Medicare. Monthly mandatory union dues Write how much you must pay each month for union dues if your job requires it. Enter 0 if none. Monthly mandatory retirement payments Write how much you are required to pay into a retirement plan each month. Do not include money you choose to add. Enter 0 if none.

b. Health & Medical Support

Monthly health insurance payments (including dental insurance), excluding portion paid for any minor children of this relationship Write your monthly cost for health and dental insurance for yourself. Do not include the part that covers your children from this relationship.

c. Child Support

Monthly court-ordered child support actually paid for children from another relationship Write the monthly child support you actually pay by court order for children from a different relationship. Enter 0 if none. Monthly court-ordered alimony actually paid (Add 25a and 25b) Add lines 25a and 25b and write the total alimony you pay each month by court order. 25a. from this case: $ Write the monthly alimony you pay because of this current case. 25b. from other case(s): $ Write the monthly alimony you pay because of other cases. Enter 0 if none. TOTAL DEDUCTIONS ALLOWABLE UNDER SECTION 61.30, FLORIDA STATUTES (Add lines 18 through 25) Add up all the deduction amounts from lines 18 through 25 and write the total here. PRESENT NET MONTHLY INCOME (Subtract line 26 from line 17) Subtract your total deductions on line 26 from your total gross income on line 17 to find your take-home pay each month. Mortgage or rent Write how much you pay each month for your house payment or rent. If you pay every two weeks, add it up for a full month. Property taxes Write your monthly cost for property taxes. If you pay once a year, divide that amount by 12. Utilities Write your monthly cost for things like electric, water, gas, and trash. Add them up for a typical month. Telephone Write how much you pay each month for your home phone or cell phone. Food Write how much you spend each month on groceries and food you eat at home. Meals outside home Write how much you spend each month eating out at restaurants or fast food. Maintenance/Repairs Write your monthly cost to fix or keep up your home, like repairs or lawn care. Other: Name any other home expense not already listed above. Other: Write the monthly cost for the other home expense you named. Gasoline Write how much you spend each month on gas for your car. Repairs Write your monthly cost to fix or maintain your car, like oil changes or tires. Insurance Write how much you pay each month for car insurance. Day care Write how much you pay each month for child care or daycare. Lunch money Write how much you give your children each month for school lunches. Clothing Write how much you spend each month on clothes for your children. Grooming Write your monthly cost for your children's haircuts and personal care items. Gifts for holidays Write how much you spend each month on holiday and birthday gifts for your children.

d. Health & Medical Support

Medical/Dental (uninsured) Write your monthly cost for your children's doctor or dental bills that insurance does not pay. Other: Name any other child expense not already listed above. Other: Write the monthly cost for the other child expense you named. Medical/Dental (if not listed on lines 23 or 45) Write your monthly cost for health or dental insurance if you did not already list it elsewhere. Child(ren)'s medical/dental Write how much you pay each month for health or dental insurance for your children. Life Write how much you pay each month for life insurance. Other: Name any other insurance you pay for that is not listed above. Other: Write the monthly cost for the other insurance you named. Clothing Write how much you spend each month on clothes for yourself. Medical/Dental (uninsured) Write your monthly cost for your own doctor or dental bills that insurance does not pay. Grooming Write your monthly cost for haircuts and personal care items for yourself. Entertainment Write how much you spend each month on fun activities like movies, hobbies, or streaming services. Gifts Write how much you spend each month on gifts for other people. Religious organizations Write how much you give each month to a church or other religious group. Miscellaneous Write your monthly cost for small expenses that do not fit any other category. Other: Name another monthly expense not already listed above. Other: Write the monthly cost for the expense you named. Other expense line Name another monthly expense not already listed above. Other expense amount Write the monthly cost for the expense you named. Other expense line Name another monthly expense not already listed above. Other expense amount Write the monthly cost for the expense you named. Other expense line Name another monthly expense not already listed above. Other expense amount Write the monthly cost for the expense you named. Other expense line Name another monthly expense not already listed above. Other expense amount Write the monthly cost for the expense you named. CREDITOR: Write the name of a person or company you owe money to and make payments to. MONTHLY PAYMENT Write how much you pay this creditor each month. CREDITOR: Write the name of another person or company you make payments to. MONTHLY PAYMENT Write how much you pay this creditor each month. CREDITOR: Write the name of another person or company you make payments to. MONTHLY PAYMENT Write how much you pay this creditor each month. CREDITOR: Write the name of another person or company you make payments to. MONTHLY PAYMENT Write how much you pay this creditor each month. CREDITOR: Write the name of another person or company you make payments to. MONTHLY PAYMENT Write how much you pay this creditor each month. CREDITOR: Write the name of another person or company you make payments to. MONTHLY PAYMENT Write how much you pay this creditor each month. CREDITOR: Write the name of another person or company you make payments to. MONTHLY PAYMENT Write how much you pay this creditor each month. CREDITOR: Write the name of another person or company you make payments to. MONTHLY PAYMENT Write how much you pay this creditor each month. CREDITOR: Write the name of another person or company you make payments to. MONTHLY PAYMENT Write how much you pay this creditor each month.