Free Financial Declaration-Spanish - New Hampshire

El Corte Distrito de los Estados Unidos (United States District Court) Distrito de New Hampshire (District of New Hampshire)

DECLARACION JURADA ECONOMICA (Financial Affidavit)
NUMERO/NOMBRE DEL CASO: (case #/ name) ______________________________________________________ NOMBRE: (name) ___________________________________________________________________________ DIRECCION: (address) ___________________________________________________________________________ ___________________________________________________________________________ Numero telefonico (phone #) _________________________ ADVERTENCIA: La información que usted suministre para obtener representación nombrada por la corte está sujeta a las siguientes limitaciones: (warning and limitations)

(1) El privilegio abogado/cliente puede no aplicar; (atty./client privilege may not apply) (2) La información está sujeta a ser archivada en la Corte para futuro examen por el Fisco de los Estados Unidos; (information to be filed with the Court) (3) Una respuesta falsa o deshonesta puede ser castigada como un crimen; (false answer may be punished) (4) Este formulario debe ser firmado bajo pena de perjuria. (form signed under penalty of perjury) CASADO(A): (married) YES (si) " NO " Numero de dependientes (# of Dependents)_______________

BIENES (assets)
I. INGRESOS (income) EMPLEADO POR: (employed) __________________________________________________________________ PAGO MENSUAL: (monthly income) BRUTO: (gross) _________________________________ NETO: (net)_____________________________ ASISTENCIA PUBLICA: (welfare) _________________ SEGURO SOCIAL: (soc. sec.) _____________ JUBILACION: (pension) __________________________ OTROS: (other) _________________________ EMPLEO DE ESPOSA (O): (spouse's employer)____________________________________________________ PAGO MENSUAL: (monthly income) BRUTO: (gross) _________________________________ NETO: (net) ____________________________ ASISTENCIA PUBLICA: (welfare) _________________ SEGURO SOCIAL (soc. sec.) _____________ JUBILACION: (pension) __________________________ OTROS: (other) _________________________ II. PROPIEDAD (property) FINCA RAIZ (real estate) 1. CASA (home) 2. OTRA (other) 3. OTRA (other) VEHICULOS (motor veh.) 1. _________________ 2. _________________ 3. _________________

VALOR (value) _________________ _________________ _________________ VALOR (value) _________________ _________________ _________________

HIPOTECA (mtg) __________________ __________________ __________________ DEBE (owed) __________________ __________________ __________________

NETO (net) ______________________ ______________________ ______________________ NETO (net) ______________________ ______________________ ______________________

III. OTROS BIENES (other assets) 1. DINERO EN MANO (cash on hand) _______________________________________________________ 2. CUENTA DE CHEQUES (checking account) ________________________________________________ 3. CUENTA DE AHORROS (savings account) _________________________________________________ 4. ASOCIACION DE CREDITO (credit union) _________________________________________________ USDCNH-15A (Rev. 01-02)(previous editions usable) (continuado de atrás) (continued on the back)

III. OTROS BIENES (other assets) (continuado) (continued) 5. CUENTAS POR COBRAR (accounts receivable) _____________________________________________ 6. JOYERIA (jewelry) _____________________________________________________________________ 7. ACCIONES (stocks) ____________________________________________________________________ 8. BONOS (bonds) ________________________________________________________________________ 9. OTROS (other) _________________________________________________________________________

LIABILITIES
I. FINCA RAIZ (real estate) PRESTAMISTA (lender) 1. _________________________ 2. _________________________ 3. _________________________ II. VEHICULOS (motor vehicles) PRESTAMISTA (lender) 1. _________________________ 2. _________________________ 3. _________________________ TOTAL DEUDA (total owed) PAGO MENSUAL (mthly pymts) ____________________________ ______________________________ ____________________________ ______________________________ ____________________________ ______________________________

TOTAL DEUDA (total owed) PAGO MENSUAL (mthly pymts) ____________________________ ______________________________ ____________________________ ______________________________ ____________________________ ______________________________

III. DEUDA GENERALES (general debts) PRESTAMISTA (lender) TOTAL DEUDA (total owed) PAGO MENSUAL (mthly pymts) 1. _________________________ ____________________________ ______________________________ 2. _________________________ ____________________________ ______________________________ 3. _________________________ ____________________________ ______________________________ 4. _________________________ ____________________________ ______________________________ 5. ________________________ ____________________________ ______________________________ IV. GASTOS DOMESTICOS (household expenses) 1. TELEFONO (phone) _________________________ 2. SERVICIOS (utilities) ________________________ 3. MANTENIMIENTO NINOS (child support) ______ 4. MANTENIMIENTO MUJER (alimony) _________ 5. ROPA (clothes) _____________________________ 6. TRANSPORTE (transportation) ________________ 7. SEGUROS (insurance) _______________________

8. ALIMENTOS (food) ______________________ 9. MEDICO/DENTISTA (doctor/dentists) _______ 10. COLEGIO (school) _______________________ 11. IGLESIA (church) ________________________ 12. IMPUESTOS (taxes) ______________________ 13. ALQUILER (rent) ________________________ 14. OTROS (other) __________________________

YO DECLARO BAJO PENA DE PERJURIA QUE ESTA INFORMACION ES VERDADERA Y CORRECTA A LO MEJOR DE MI CONOCIMIENTO Y CREENCIA. (I declare under penalty of perjury that the foregoing information is true and correct to the best of my knowledge and belief.)

______________________________ FECHA (date)

______________________________________________ FIRMA (signature)

PETICION APROBADA: (approved) ( ) PETICION NEGADA: (disapproved) ( )

______________________________ FECHA (date)

_____________________________________________________ JUEZ MAGISTRADO DE LOS ESTADOS UNIDOS (United States Magistrate Judge) JUEZ DISTRITAL DE LOS ESTADOS UNIDOS (United States District Judge)