Free Affidavit of Financial Status - Kansas

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IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF KANSAS _________________________________ Plaintiff(s), vs. ________________________________ ________________________________ Defendant(s). ) ) ) ) ) ) ) ) ) )

Case No. _________________________

AFFIDAVIT OF FINANCIAL STATUS1

I, _____________________________________, state that I am the plaintiff in this case and that the following information regarding my current financial status is true. I. PERSONAL DATA AND MARITAL STATUS: A. My address:

My telephone: My age :_____________ B. Single: _____ Married: _____ Separated: _____ Divorced: _____ Spouse's name:______________________________________ Spouse's age: _____________ Spouse's address (if different from mine): _____________________________

Spouse's telephone (if different from mine): _________________

Access to this document is restricted pursuant to the court's policy to protect the personal privacy interest of the parties (see Rule 5.4.14 of the Rules of Practice and Procedures for District and Bankruptcy Court.)

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C.

Names of dependents who live with me or who I am legally required to support financially: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Ages of dependents: ____________________________________________________________ Relationship of dependents to me: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Amount of monthly support I give each dependent: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________

II.

EMPLOYMENT A. Currently employed? Yes ____ No______ If currently employed: Name of employer: ________________________________________________ Address of employer: ______________________________________________ Employer's telephone: ______________________________________________ Length of employment: _____________________________________________ Job title or description: _____________________________________________ Net (take home) income: Monthly $__________ or Weekly $__________

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Does employer provide health insurance? Yes ____ No _____ If employer provides health insurance, what kind? ____________________________________________________________ ____________________________________________________________ B. Previous Employment (answer only if currently unemployed) . Name of employer: ________________________________________________ Address of employer: ______________________________________________ Employer's telephone: _____________________________________________ Length of employment: ____________________________________________ Job title or description: _____________________________________________ Net (take home) income: C. Employment of spouse: Name of employer: ________________________________________________ Address of employer: ______________________________________________ Employer's telephone: ______________________________________________ Length of employment: _____________________________________________ Job title or description: _____________________________________________ Net (take home) income: III. FINANCIAL STATUS A. Do you or your spouse own real property? If yes -Description: Address: _________________________________________________________ In whose name: ___________________________________________________ Yes ____ No _____ Monthly $__________ or Weekly $__________ Monthly $__________ or Weekly $__________

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Estimated value $____________ Total amount owed $__________ Owed to:_________________________________________________________ Annual income from property $__________ B. Do you or your spouse own any automobiles? If yes, number of automobiles owned: __________ Make __________ Make __________ Model __________ Model __________ Year __________ Year __________ Yes _____ No _____

In whose name registered: ___________________________________________ Present value $__________ Amount owed on the automobile(s) $__________ Owed to: ________________________________________________________ Monthly payment(s) $__________ C. Total amount of cash on hand, in my checking account(s) or savings account(s): $____________________ If not joint account(s) with my spouse, total amount in my spouse's checking account(s) or savings account(s): $____________________

D.

In the last 12 months, have you or your spouse received any money from any of the following sources? Yes No Amount Unemployment benefits: _____ ____ ____ ____ $ $ $

Welfare payments: _____ ADC or other governmental child support: _____ 4

Social Security benefits: Pensions, trust funds, annuities or life insurance payment: Other gov't sources (exampleMedicaid benefits): Gifts or inheritances: Other sources (example-judgments in other cases or insurance proceeds): IV. OBLIGATIONS A. B.

_____

____

$

_____

____

$

_____ _____

____ ____

$ $

_____

____

$

Monthly mortgage or rental payment on house or apartment $__________ Monthly mortgage payment(s) on other properties $__________ Amount of equity in other properties $__________

C.

Monthly household expenses: Grocery expense Gas Electric Cable $__________ $___________ $___________ $

Phone (includes cell) $ Water Car Insurance Health Insurance Life Insurance D. $___________ $___________ $ ___________ $____________

Other monthly debts and miscellaneous expenses (examples-credit cards, medical bills, alimony, child support, student loans, tax lien or other gov't liability). To whom owed and for what reason incurred: 5 Monthly Balance Due

Payment

V.

OTHER INFORMATION PERTINENT TO FINANCIAL STATUS: A. Have you ever filed for bankruptcy? Yes ____ No ____

B.

Information regarding stocks, bonds, savings bonds, either owned individually or jointly. __________________________________________________________________ __________________________________________________________________ _________________________________________________________________

I understand that a false statement or answer to any question in this affidavit will subject me to penalties of perjury. _____________________________________ Signature of Plaintiff _____________________________________ Name (Print or Type) _____________________________________ _____________________________________ Address _____________________________________ City State Zip Code _____________________________________ Telephone

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