Free Motion for Miscellaneous Relief - District Court of Connecticut - Connecticut

Case 3:03-cr-00025-PCD
FINANCIAL AFFIDAVIT(please type or print)

Document 6

Filed 10/16/2006

Page 1 of 2

SECTION I. PERSONAL DATA
Mr. Mrs. Ms. Miss.

last name

first

middle initial

social security

date of birth

complete address (including city/state/zip code)

home phone

work phone

Martial status (please check) single married widowed divorced

License No. separated

name of spouse

social security number

date of birth

age(s) of dependents (if older than 21 please list dependant's name and reason for dependency) SECTION II. HISTORY OF EMPLOYMENT

name/address of current employer SPOUSE EMPLOYMENT

occupation

years/months employed

name/address of current employer

occupation

years/months employed

AVERAGE MONTHLY INCOME MONTHLY GROSS SALARY (before payroll deductions) DEDUCTIONS FEDERAL/STATE/LOCAL INCOME TAXES RETIREMENT SOCIAL SECURITY OTHER (SPECIFY) TOTAL DEDUCTIONS

HUSBAND

WIFE

MONTHLY EXPENSES RENT/ MORTGAGE PAYMENT FOOD UTILITIES/HEAT

AMOUNT

$

$

TELEPHONE INSURANCE CLOTHING $ $ $ MEDICAL (NON REIMBURSABLE) AUTO REPAIR/ OTHER LIVING EXPENSES

NET TAKE HOME PAY

Combined monthly income:

How much of the balance can you apply to your debt to the U.S. on a monthly basis? $

If total monthly expenses exceed monthly income, how do you pay the difference? Total monthly expenses:

"Exhibit A"

Case 3:03-cr-00025-PCD

Document 6

Filed 10/16/2006

Page 2 of 2

SECTION III ASSETS NAME/ADDRESS OF BANK INSTITUTION: Do you own: (please circle) 1. U.S. savings bonds? bank account balance: $ checking $ savings other 3. Do you own any property? Yes (if not continue) complete address of property: cash value of furniture and household goods: $ (current value) $ automobile(s): (estimate value of each vehicle) make year model trailer/boats/campers (resale value):$ 1. 2. SECTION IV. INSTALLMENT CONTRACTS/OTHER DEBTS **Show here all debts which you are required to pay in regular monthly installments. Do not include living expenses.**
NAME OF CREDITOR PURPOSE OF DEBT ORIGINAL AMOUNT OF DEBT $ UNPAID BALANCE AMOUNT DUE MONTHLY AMOUNT PAST DUE

Yes Yes

No No No

2. stocks and other bonds?

$

**N O TE: IF R EPA YM EN T O F D EBT IS N O T O N A M O N TH LY BA SIS, PLEA SE EXPLA IN W H EN PA YM EN T IS D U E**

H ave you ever been in bankruptcy? Are you currently in the m ilitary?

If yes, date discharged yes no

location of court (city/state)

docket num ber

If applicable, what is your present unit assigned?

total years active duty

***PLEASE U SE ADD ITIO N AL SH EETS, IF N ECESSARY TO SU PPLY AN Y O THER PERTIN ENT IN FO RM ATIO N ABO U T YO U R FIN AN CIAL STATU S.*** W ith know ledge of the penalties for false statem ents provided by 18 U .S.C. § 1001, $250,000 fine and five years imprisonment and w ith know ledge that this financial statement is submitted by me to affect action by the D epartment of Justice, I certify that I believe the above statement is true and that it is a com plete statement of all incom e and assets, real and personal, w hether held in my nam e or be any other. I hereby certify that this financial statement is made to affect action by the D epartment of Justice regarding a debt of $24,004.10 as of O ctober 16, 2006, w hich I acknow ledge is due and ow ing to the U nited States.

signature of debtor

date signed