Free Affidavit of Financial Status - Michigan

UNITED STATES DISTRICT COURT WESTERN DISTRICT OF MICHIGAN

Plaintiff(s) vs.

Case No.

Defendant(s)

AFFIDAVIT OF FINANCIAL STATUS The undersigned, with knowledge that there are criminal penalties for false statements, makes the following statements regarding marital status, r esidence, employment and financial status: I. MARITAL STATUS: a. Single Married b. D ependents: Spouse RESIDENCE: Your address: Street City Telephone III. EMPLOYMENT: Are you now employed? If now employed: Address of Employer Yes No State Zip Code

Separated Children, No.

Divorced Others, No.

II.

Name of Employer

Employer' s Telephone

How long have you been employed by present employer? Income: Monthly $ Weekly $

What is your job? Other Income IV. FINANCIAL STATUS: 1. Owner of real property: a. Description b. Address c. In whose name d. Estimated value e. Total amount owed $ f. Annual income from property 2. Other property a. Automobile: Make b. In whose name registered c. Present value of car $ d. Amount owed $ 3. Cash on hand: $ a. Cash in banks and savings and loan associations $ b. Names and addresses of banks and associations Year To whom Yes No

4.

Obligations: a. Monthly rental on house or apartment b. Mortgage payments on house (monthly) c. Other debts: To whom owed $ Amount $ $

Total monthly payments on debts: 5.

$

Other information pertinent to your financial status: (Include stocks, bonds, savings bonds, interests in trusts, either owned or jointly owned, ADC, unemployment, social security, or other. specify which.) Please

I declare under the penalty of perjury that the foregoing is true and correct.

Dated:

Signed:
Plaintiff-Affiant