IN THE COUNTY COURT OF THE TENTH JUDICIAL CIRCUIT

IN AND FOR POLK COUNTY, FLORIDA

CASE NO. ____________________________

_________________________________________,

Affiant.

FINANCIAL AFFIDAVIT AND AFFIDAVIT OF INSOLVENCY

I, ____________________________________, after being properly placed under oath, do swear or affirm that I have no money or means to pay the filing fee and costs associated with my lawsuit; that I believe my lawsuit asks the Court for relief to which I am legally entitled; and that the following information is true and correct. I understand that if the information I provide below misleads the Court in determining my insolvency, I may be subject to contempt of court or charged with the crime of perjury.

EMPLOYMENT AND INCOME

OCCUPATION:          __________________________________________ SOC. SEC. #: ______________________________________

EMPLOYED BY: __________________________________________ PAY PERIOD: ______________________________________

ADDRESS:         __________________________________________ RATE OF PAY: ______________________________________

                               __________________________________________

AVERAGE GROSS MONTHLY INCOME FROM EMPLOYMENT                                                                                                                            $_____________

Bonuses, commissions, allowance, overtime, tips and similar payments                                                                                                            $_____________

Business income from sources such as self-employment, partnership, close corporations, and/or independent contracts (gross receipts

minus ordinary and necessary expenses required to produce income)                                                                                                              _____________

Disability benefits                                                                                                                                                                                                      _____________

Worker’s Compensation                                                                                                                                                                                              _____________

Unemployment Compensation                                                                                                                                                                                      _____________

Pension, Retirements and Annuity Payments                                                                                                                                                              _____________

Social Security Benefits                                                                                                                                                                                              _____________

Spousal Support Received from Previous Marriage                                                                                                                                              _____________

Interest and Dividends                                                                                                                                                                                              _____________

Rental Income (gross receipts minus ordinary and necessary expenses required to produce income)                                                              _____________

Income from Royalties, trust or estates                                                                                                                                                                      _____________

Reimbursed expenses and in kind payments to the extent that they reduce personal living expenses                                                              _____________

Gains derived from dealing in property (not including non-recurring gain)                                                                                                              _____________

Itemize any other income of a recurring nature                                                                                                                                                      _____________

TOTAL MONTHLY INCOME                                                                                                                                                                                    $_____________

LESS DEDUCTIONS:                                                                                                                                               $_____________

Federal, state and local income taxes (corrected for filing sums and actual number of withholding allowances) _____________

FICA of self-employment tax (annualized)                                                                                                                 _____________

Mandatory union dues                                                                                                                                                 _____________

Mandatory retirement                                                                                                                                                 _____________

Health Insurance Payments                                                                                                                                         _____________

Court ordered support payments for the children actually paid                                                                                 _____________

TOTAL DEDUCTIONS                                                                                                                                                                                            $_____________

AVERAGE MONTHLY EXPENSES

HOUSEHOLD:                                                                                                              INSURANCES:

 

Mtg. or rent payments        _______________________

Property taxes & insurance _______________________                                      Health                                                                                    $_____________

Electricity                                 _______________________                                      Life                                                                                      _____________

Water, garbage & sewer _______________________                                     Other Insurance                                                                      _____________

Telephone                         _______________________                                     _______________________________________

Fuel Oil or natural gas         _______________________                                     _______________________________________

Repairs and Maintenance _______________________

Lawn and pool care        _______________________                                    OTHER EXPENSES NOT LISTED ABOVE

Pest Control                         _______________________                                    Dry cleaning and laundry                                                      _____________

Misc. Household                 _______________________                                    Affiant’s clothing                                                                      _____________

Food and grocery items         _______________________                                    Affiant’s medical/dental                                                      _____________

Meals outside home                 _______________________                                    Prescriptions                                                                      _____________

Other                                 _______________________                                    Affiant’s beauty parlor                                                              _____________

____________________ _______________________                                    Affiant’s gifts (special holidays)                                              _____________

AUTOMOBILE:                                                                                                    PETS:

Gasoline and oil                ___________________                                           Grooming                                                                             _____________

Repairs                                ___________________                                           Veterinarian                                                                             _____________

Auto tags and license        ___________________                                           Membership Dues:                                                                     _____________

Insurance                       ___________________                                           Professional Dues:                                                             _____________

Other:                               ___________________                                          Social Dues:                                                                             _____________

______________________________________                                                  Entertainment                                                                             _____________
______________________________________                                                  Vacations                                                                             _____________

                                                                                                                                Publications                                                                             _____________

                                                                                                                                Charities                                                                                     _____________

CHILDREN’S EXPENSES:

 

Nursery or babysitting   ___________________                                         Miscellaneous

School tuition                    ___________________                                         Other                                                                                      _____________

School supplies            ___________________                                         _________________________________                              _____________

Lunch Money                    ___________________                                         _________________________________                              _____________  

Allowance                    ___________________                                         _________________________________                              _____________

Clothing                            ___________________                                         _________________________________                              _____________

Medical, dental prescription ___________________

Vitamins                           ___________________                                         TOTAL ABOVE EXPENSES:                                                    $_____________  

Barber/beauty parlor  ___________________

Cosmetics/toiletries            ___________________                                         PAYMENTS TO CREDITORS:

Gifts for special holiday     ___________________

Other                            ___________________                                         TO WHOM                                              BALANCE             MONTHLY

                                                                                                                                                                                                     DUE                     PAYMENT

                                                                                                                                _______________________________     _____________     _____________

                                                                                                                                _______________________________       _____________     _____________

                                                                                                                                _______________________________     _____________     _____________

                                                                                                                                _______________________________     _____________     _____________

                                                                                                                                Total Monthly Payments to Creditors                                    $_____________

                                                                                                                                TOTAL MONTHLY EXPENSES                                            $_____________

ITEM 3:

ASSETS (Ownership: if joint, allocate equally)

Description                                                                                                 Value                               Husband                                  Wife

Cash (on hand or in banks)                                                                          __________________ _______________________  ______________________

Stocks/bonds/notes                                                                                  __________________ _______________________  ______________________

Real Estate:

Home:                                                                                                           __________________ _______________________   _____________________

________________________________________                                   __________________ _______________________  ______________________

________________________________________                                   __________________ _______________________  ______________________

Automobiles:

________________________________________                                  __________________   _______________________  ______________________

________________________________________                                   __________________ _______________________  ______________________ 

Other Personal Property:

Contents of Home                                                                                           __________________ _______________________  ______________________

Jewelry                                                                                                           _________________    _______________________  ______________________

Life Ins./cash surrender value                                                                  __________________ _______________________  ______________________

Other Assets

________________________________________                                  __________________ _______________________ ______________________

________________________________________                                  __________________ _______________________  ______________________ 

TOTAL ASSETS                                                                                        $__________________ $_______________________  $______________________

ITEM 4: Liabilities LIABILITIES

Creditor                         Security                                                                  Balance                          Husband                                    Wife

________________________________________                                  __________________ _______________________ ______________________

________________________________________                                  __________________ _______________________ ______________________

________________________________________                                  __________________ _______________________ ______________________

TOTAL LIABILITIES                                                                                $__________________ $_______________________ $______________________

______________________________________________

Affiant

Subscribed and sworn to before me this ______ day of _____________________, 19____

RICHARD M. WEISS, Clerk

By_____________________________________                                              _____     Personally Known

            Deputy Clerk

                OR                                                                                                      _____     Produced Identification

By_____________________________________                                                            Type of identification presented: _____________________________

Notary Public

My Commission expires ____________________

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