Financial Disclosure Form · Step 3 of 4

Signature & Certification

I swear or affirm under penalty of perjury that I have read and followed all instructions in completing this Financial Disclosure Form. I understand that, by my signature, I guarantee the truthfulness of the information on this Form. I also understand that if I knowingly make false statements I may be subject to punishment, including contempt of court. Write your initials here to confirm you read this and that everything you wrote is true. I have attached a copy of my 3 most recent pay stubs to this form. Write your initials here if you are attaching your last 3 pay stubs. I have attached a copy of my most recent YTD income statement/P&L statement to this form, if self-employed. Write your initials here if you are self-employed and attaching your year-to-date income or profit-and-loss statement. I have not attached a copy of my pay stubs to this form because I am currently unemployed. Write your initials here only if you are not attaching pay stubs because you do not have a job right now. Signature Sign your name to show the information on this form is true. Date Enter the date you signed this form. That on (date) Enter the date you sent or delivered the form to the other party. This is the day service happened. Via 1st Class U.S. Mail, postage fully prepaid addressed as follows: Check this box if you mailed the form using regular U.S. Mail with prepaid postage. Via 1st Class U.S. Mail, postage fully prepaid addressed as follows: Write the full name and mailing address of the person you mailed the form to. Via Electronic Service, in accordance with the Master Service List, pursuant to NEFCR 9, to: Check this box if you sent the form through the court's electronic filing system. Via Electronic Service, in accordance with the Master Service List, pursuant to NEFCR 9, to: Write the name of the person or party who received the form electronically. Via Facsimile and/or Email Pursuant to the Consent of Service by Electronic Means on file herein to: Check this box if you sent the form by fax or email because the other party agreed to receive it that way. herein to: Write the name, fax number, or email address of the person you sent the form to. Executed on the _____ day of Enter the day of the month you signed this form, such as 15. day of ______________ Enter the month you signed this form, such as January. , 20___ Enter the last two digits of the year you signed this form, such as 24 for 2024. Signature Sign here to confirm that everything in this form is true and that you served the other party as described.

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