Free FINANCIAL AFFIDAVIT - Connecticut


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FINANCIAL AFFIDAVIT
JD-FM-6 Rev. 1-08 P.B. 25-30

STATE OF CONNECTICUT SUPERIOR COURT
www.jud.ct.gov
AT (Address of court)

COURT USE ONLY

FINAFF
DOCKET NO. NAME OF AFFIANT (Person submitting this form)

FOR THE JUDICIAL DISTRICT OF NAME OF CASE

PLAINTIFF
NAME OF EMPLOYER

DEFENDANT

OCCUPATION ADDRESS OF EMPLOYER

A. WEEKLY INCOME FROM PRINCIPAL EMPLOYMENT (Use weekly average not fewer than 13 weeks)
DEDUCTIONS (Taxes, FICA, etc.) AMOUNT/WEEK DEDUCTIONS (Cont ) AMOUNT/WEEK

1. 2. 3.

$ $ $

4. 5. 6.

$ $ $

GROSS WKLY WAGE FROM PRINCIPAL EMPLOYMENT TOTAL DEDUCTIONS NET WEEKLY WAGE

$ $ $

B. ALL OTHER INCOME (Include in-kind compensation, gratuities, rents, interest, dividends, pension, etc.)
1. WEEKLY INCOME
SOURCE OF INCOME GROSS AMT/WK SOURCE OF INCOME GROSS AMT/WK

1.
DEDUCTIONS

$
AMOUNT/WEEK

2.
DEDUCTIONS

$
AMOUNT/WEEK

GROSS WEEKLY INCOME FROM OTHER SOURCES TOTAL DEDUCTIONS NET WEEKLY INCOME FROM OTHER SOURCES

$ $ $

$ $ $ $ $ $ 1. RENT OR MORTGAGE 2. REAL ESTATE TAXES
Fuel Electricity

$ $ $ $ $ $
Gas/Oil

ADD "NET WEEKLY WAGE" FROM SECTION A, AND "NET WEEKLY INCOME" FROM SECTION B, AND ENTER TOTAL BELOW:

A.

TOTAL NET WEEKLY INCOME

$
$

$ $ $ $ $ $ 7. INSURANCE PREMIUMS 6. TRANSPORTATION

$ $ $ $ $ $ $ $ $ $ $ BALANCE DUE $ $ $ $ $ $

11. DAY CARE 12. OTHER (specify below)

Repairs Auto Loan Public Trans. Medical/ Dental Automobile Homeowners Life

$ $ $ $ $ $ $ $ B.
TOTAL WEEKLY EXPENSES

2. WEEKLY EXPENSES

Gas

3. UTILITIES

Water

Telephone $ Trash Collection

$

Cable T.V. $

8. MEDICAL/DENTAL

9. CHILD SUPPORT 4. FOOD $ (order of court) 10. ALIMONY 5. CLOTHING $ (order of court) AMOUNT OF CREDITOR (Do not include mortgages or loan DEBT balances that will be listed under assets.) $ $ 3. LIABILITIES (DEBTS) $

$
WEEKLY PAYMENT $ $ $ $ $ $

DATE DEBT INCURRED

$
$ $ C. TOTAL LIABILITIES (Total Balance Due on Debts) (continued)

$

D. LIABILITY EXPENSE

TOTAL WEEKLY

$

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ADDRESS

VALUE (Est )

MORTGAGE

EQUITY

Home A. Real Estate
ADDRESS

$
VALUE (Est )

$
MORTGAGE

$
EQUITY

Other:
ADDRESS

$
VALUE (Est )

$
MORTGAGE

$
EQUITY

Other:
YEAR MAKE MAKE

$
MODEL MODEL VALUE

$
LOAN BALANCE

$
EQUITY

B. Motor Vehicles

Car 1:
YEAR

$
VALUE

$
LOAN BALANCE

$
EQUITY

Car 2:
DESCRIBE AND STATE VALUE OF EACH ITEM

$

$

$ TOTAL VALUE

C. Other Personal Property

$
BANK NAME, TYPE OF ACCOUNT, AND AMOUNT

D. Bank Accounts 4. ASSETS

TOTAL BANK ACCOUNTS

$
NAME OF COMPANY, NUMBER OF SHARES, AND VALUE

E. Stocks, Bonds Mutual Funds
NAME OF INSURED COMPANY FACE AMOUNT CASH VALUE AMT. OF LOAN

TOTAL VALUE

$
$ $ $
NAME OF PLAN (Individual I.R.A., 401K, Keogh, etc ) AND APPROX. VALUE

F. Insurance (exclude children)

$ $ $

$ $ $

TOTAL VALUE

$
TOTAL VALUE (less loans)

G. Deferred Compensation Plans

$
TOTAL VALUE

H. All Other Assets

$
I. Total 5. HEALTH INSURANCE E. TOTAL CASH VALUE OF ALL ASSETS

$

NAME AND ADDRESS OF HEALTH OR DENTAL INSURANCE CARRIER (Do not include policy number)

NAME(S) OF PERSON(S) COVERED BY THE POLICY

SUMMARY (Use the amounts shown in boxes A thru E of sections 1-4.) TOTAL NET WEEKLY INCOME (A) TOTAL WEEKLY EXPENSES AND LIABILITIES (B + D)

$ $

TOTAL CASH VALUE OF ASSETS (E) TOTAL LIABILITIES (TOTAL BALANCE DUE ON DEBTS) (C)

$ $

CERTIFICATION I certify that the foregoing statement is true and accurate to the best of my knowledge and belief.
SIGNED (Affiant)

Subscribed and sworn DATE to before me on

SIGNED (Notary, Comm. of Superior Court, Assistant Clerk)

JD-FM-6 Rev. 1-08 (Back)

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