Free IN DISTRICT COURT, - North Dakota

IN DISTRICT COURT,

COUNTY, STATE OF NORTH DAKOTA

, Plaintiff, vs.

, Defendant.

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FINANCIAL AFFIDAVIT IN SUPPORT OF PETITION FOR WAIVER OF FEES DATE: Civil No.

STATE OF NORTH DAKOTA COUNTY OF

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ss.

I, A. ASSETS I have cash on hand:

, being first duly sworn state as follows:

$ $ $

I have on deposit in financial institutions: I have stocks and bonds in the amount of: Total

0

Other assets and approximate value are (list): ITEM VALUE $ $ $ $ $ Total

IN POSSESSION OF

0 (Attach additional schedules as needed)
0

Total Assets $

B.

LIABILITIES. CREDITORS UNPAID BALANCE $ $ $ $ $ $ TOTAL (Attach additional schedules as needed)
0

MONTHLY PAYMENT $ $ $ $ $ $
0
0

Total Liabilities:

C.

INCOME. My monthly income, and that of my spouse, is as follows: AFFIANT GROSS INCOME DEDUCTIONS FEDERAL TAX FICA MEDICARE STATE TAX HEALTH INSURANCE RETIREMENT SAVINGS OTHER TOTAL DEDUCTIONS NET INCOME $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ SPOUSE

My pay period is every __________________________. My spouse's pay period is every __________________________.

D.

EXPENSES. My current monthly expenses to support myself and my child(ren) are as follows:

HOUSE/RENT PAYMENT GAS/ELECTRICITY HOMEOWNER'S/RENT INSURANCE WATER TELEPHONE CABLE/SATELLITE TELEVISION FOOD AND HOUSEHOLD ITEMS CLOTHING LAUNDRY LIFE INSURANCE AUTOMOBILE INSURANCE MEDICAL INSURANCE TRANSPORTATION CHILD CARE SCHOOL EXPENSES UNREIMBURSED MEDICAL, DENTAL, OPTICAL NEWSPAPER AND MAGAZINES DONATIONS ENTERTAINMENT MISCELLANEOUS TOTAL

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

0

DATED:

My Signature (Sign only in presence of notary public or Clerk of Court)

Street Address

City/State/Zip

Subscribed and sworn to before me on

, 20______.

Notary Public or Clerk of Court