Free NHJB-2534-D - New Hampshire

THE STATE OF NEW HAMPSHIRE
JUDICIAL BRANCH
http://www.courts.state.nh.us

Court Name: Case Name: Case Number:
(if known)

FINE PAYMENT FINANCIAL AFFIDAVIT
Name: Address: Date of Birth: Marital Status: Single Age: Married Divorced Separated Telephone #: H: W: C:

List all dependents you currently support, including your spouse, or any other persons who reside with you (name, relationship, date of birth, and address if different from your own). A. B. C. D. SELF (A) $ $ $ $ $ $ SPOUSE/ADULT IN HOUSEHOLD (B)

1. Available Money
a. Cash on hand b. Checking account Bank name: c. Savings account Bank name: d. Credit cards (list the balance): VISA: Mastercard: Other: Available credit on credit cards e. Stocks, Bonds, Trusts, CDs, Other f. Christmas Club g. Other TOTAL (1) $ $ $ $ $ $ $ $

$ $ $ $ $ $ $ $ (1A) (1B)

NHJB-2534-D(06/09/2008)

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Case Name: Case Number: FINE PAYMENT FINANCIAL AFFIDAVIT

2. Monthly Income
(To convert weekly income to monthly, multiply by 4.333)

SELF (A) $ $ $ $ $ $ $ $ $ $ $ $ (2A) $ (1A & 2A) $ $ $ $ $ $ $ $ $ $ $ $

SPOUSE/ADULT IN HOUSEHOLD (B)

a. Wages - Take Home Pay b. Commissions, Bonuses, Tips c. Unemployment compensation*** d. Veteran's Benefits *** e. Social Security, Pension, Disability, etc.*** f. Workmen's compensation *** g. Alimony or Child Support received*** h. Interest and Dividends Income i. Public assistance/Welfare received*** j. Rental Income k. Other TOTAL (2)
A. TOTAL CASH AVAILABLE & MONTHLY INCOME:

(2B) $ (1B & 2B)

Employment
a. Employer b. Address c. Phone number d. Hours per week

SELF (A)

SPOUSE/ADULT IN HOUSEHOLD (B)

Full time Seasonal

Part time

Full time Seasonal

Part time

If presently unemployed, state the name and address of your last employer and date(s) of employment. a. Employer b. Address c. Phone number d. Hours per week Full time Part time Seasonal If you have no present income, state how you meet your expenses: Reason for unemployment:

Dependency Status Are you claimed as an exemption on anyone else's income tax form:
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Yes

No

Case Name: Case Number: FINE PAYMENT FINANCIAL AFFIDAVIT

3. Assets
1. Property (Use Fair Market Value for all amounts listed) Do you own a house or other real estate? Market Value Mortgage Held By Market Value Mortgage Held By 2. Motor Vehicles (autos, trucks, recreational vehicles ,boats, motorcycles, trailers, etc.) Make Market Value Title Holder Make Market Value Title Holder 3. Do you own any other property that is jointly owned with any other person or entity? Yes (If yes list) Market Value Mortgage Held by 4. Sale/Transfer Have you sold or transferred any real estate or personal property worth $200.00 or more Yes (If yes list) No within the last six months? Item Date of Sale Amount Received in Sale or Transfer $ Item Date of Sale Amount Received in Sale or Transfer $ Buyer's Name Value $ Buyer's Name Value $ $ No Mortgage Owed $ $ Model Amount Owed $ Year $ Model Amount Owed $ Year $ Mortgage Owed $ $ Yes (If yes list) Mortgage Owed $ No

4. Money Owed to You
Does anyone owe you money? Who owes you money? When do you expect to be paid? Who owes you money? When do you expect to be paid?
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Yes (If yes list)

No

Amount owed $ Amount owed $

Case Name: Case Number: FINE PAYMENT FINANCIAL AFFIDAVIT

Are you the beneficiary of any estate or trust? What is the value? $ What is the value? $ List trustee/fiduciary name and address

Yes (if yes list)

No

When do you expect to receive it? When do you expect to receive it?

List trustee/fiduciary name and address List income taxes paid last year: List income tax refund received last year: $ $

5. Monthly Expenses
(To convert weekly income to monthly, multiply by 4.333)

1. Housing a. Rent/Mortgage Payment b. Property Tax c. Condo Fee d. Maintenance/Improvements e. Snow Removal/Lawn Care f. Other 2. Utilities a. Heating Oil b. Wood and Coal c. Propane/Natural Gas d. Telephone e. Electricity f. Cable Television g. Internet h. Water and Sewer i. Trash Collection j. Other 3. Insurance a. Homeowner b. Renter c. Vehicle d. Health e. Dental f. Disability g. Life h. Other $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

6. General and Personal a. Groceries/Toiletries b. Meals Eaten Out c. Tobacco/Alcohol d. Clothing/Shoes e. Hair Care/Cosmetics f. Pet Food and Care g. Church/Charities h. Laundry/Dry Cleaning i. Gifts j. Newspapers/Magazine k. Education (personal) l. Dues/Memberships m. Vacations n. Entertainment/Recreation o. Visitation Expenses p. Cellular Telephone(s) $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

$ q. Other 7. Children's Expenses and Activities a. Clothing and Shoes $ b. Diapers c. Day Care d. School Supplies e. School Lunches f. Tuition and Lessons g. Sports/Camps h. Other $ $ $ $ $ $ $

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Case Name: Case Number: FINE PAYMENT FINANCIAL AFFIDAVIT

4. Uninsured Health Care a. Medical b. Dental c. Orthodontic d. Eye care/Glasses/Contacts e. Prescription drugs f. Therapy/Counseling g. Other 5. Transportation a. Primary Vehicle Payment b. Other Vehicle Payments c. Vehicle Maintenance d. Gas/Oil e. Registration fees f. Other

$ $ $ $ $ $ $

8. Financial a. Federal Income tax b. Social Security/Medicare c. Loan payments d. Education loan e. 401(k)IRA f. IRA g. Other 9. Other Expenses

$ $ $ $ $ $ $

$ $ $ $ $ $

(List only those payments made on a regular basis) (DO NOT list any payments already listed elsewhere. e.g. rent, utilities, etc)

a. b. c. d. e. f.

$ $ $ $ $ $

B. TOTAL MONTHLY EXPENSES (1-9) Financial Resources available : A. B.

$

transfer figures from A & B to calculate amount: $ $ = $

Total cash and monthly income: Total monthly expenses:

BALANCE:

***Note: Some sources of income are protected from federal and state law from execution, levy, attachment or garnishment. If any sources of your income fall into these categories, the court will determine whether or not you will be required to pay a civil judgment. You may be ordered by the court to use some of this income to pay taxes, child support, restitution and criminal fines.***

I understand that it is my responsibility to notify the court in writing of any change of my address and/or financial circumstances. I swear (affirm) under penalties of law that to the best of my knowledge and belief the foregoing information is correct and complete.

Date

Signature

NHJB-2534-D(06/09/2008)

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