Free Affidavit of Assets and Liabilities - New Hampshire

Clear Form

STATE OF NEW HAMPSHIRE SUPREME COURT
Docket No. v. Plaintiff 1. Name: 2. Where do you live: 3. Marital Status: Single Married Divorced Separated Widowed 4. List the names, ages, and relationships of dependents you support: DOB: Defendant

AFFIDAVIT OF ASSETS AND LIABILITIES

5. If you are presently employed, state where and for how long:

Full Time

Part Time

6. If unemployed, state last date of employment: 7. When do you anticipate new employment: 8. If your spouse is presently employed, state where and for how long: 9. If your spouse is unemployed, state last date of employment: 10. List other employed household members and their weekly income: 11. Please state weekly take-home amount: Salary/Wages Pension/Trust Benefits Unemployment Comp. Social Security Investment Income Alimony Child Support Welfare Payments Other TOTAL 12. What money is presently available to you: Cash on hand Checking Account
Name of Bank

YOURS $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
Name of Bank

SPOUSE'S

Savings Account Stocks/Bonds/Ira/Pension
Identify

$ TOTAL $

13. (If inmate) State amount deposited in inmate's account for the last three months: $

14. Please state your monthly household expenses: Rent/Mortgage $ Property Taxes Heat Food Utilities Medical/Dental Insurance $ $ $ $ $ $

Clothing

$

Transportation $
(including gas, maintenance, insurance, repairs)

Other

$
(specify type of expense):

TOTAL $ 15. List any real estate you own, its market value and the amount you owe: 16. List any vehicles you own (car, truck, motorcycle, snowmobile, RV), their market value and the amount you owe: 17. List income tax paid last year: 18. List income tax refund received last year: 19. Other than monthly household expenses, list any bills you owe, amount owed, to whom, and monthly payments: 20. Other than those previously mentioned, list anyone to whom you owe money, amount and when it is due: 21. List court-ordered bills (i.e., alimony, judgment in law suit, etc.): 22. If anyone owes you money, state name, address, amount due, and when due: 23. List any property you have transferred within the last three years, to whom and for what price: 24. List any other assets or expenses not previously mentioned: IF YOU NEED ADDITIONAL SPACE TO ANSWER ANY QUESTION ABOVE, ATTACH A SHEETOF PAPER TO THIS FORM AND PROVIDE THE ADDITIONAL INFORMATION ON IT.

I swear the foregoing information and any information provided by me on any attached sheets is true and correct to the best of my knowledge under penalties of law.
Date Signature

(The following section must be completed only by inmates.)

I swear under oath that this civil claim has not been previously brought against the same parties or from the same operative facts in any state or federal court. I further swear that the foregoing information and any information provided by me on any attached sheets is true and correct to the best of my knowledge under penalties of law.
Date
Subscribed and sworn by appellant, before me.

Signature

Date

Notary Public
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