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New Hampshire Financial Affidavit Form

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New Hampshire Financial Affidavit Form
New Hampshire Financial Affidavit Form
NHJB-2065-FS (03/25/2013) Page 1 of 5
THE STATE OF NEW HAMPSHIRE
JUDICIAL BRANCH
http://www.courts.state.nh.us
Court Name:
Case Name:
Case Number:
(if known)
FINANCIAL AFFIDAVIT
1. General Information
Name
Street Address
Town/City, State, Zip
Mailing Address, if different
Date of Birth
Social Security Number
Highest Grade or Degree Completed
Date of Marriage
Date of Separation or Divorce
2. Children born to, or adopted by, the Parties (Full Name, DOB, and SSN)
2a. Number of people currently living in household including self:
3. Employment Information
Name, Address, and Phone Number of Employer
Date and Place of Last Employment
Job Skills
4. Monthly Income - Miscellaneous
AFDC, TANF, and Food Stamps
Other Public Assistance
Children's Income
Child Support
5. Monthly Income Before Taxes
Base Pay from Salary, Wages
Overtime and Shift Differential
Commissions, Tips, Bonuses
Part-time Employment
Self-employment
Unemployment and Veteran's Benefits
Disability, Workers' Compensation
Pension and Retirement Benefits
Social Security Benefits (SSA)
Interest and Dividends
Trust and Other Investment Income
Rental Income and Business Profits
All other sources
Total Section 5 Monthly Income
6. Monthly Expenses
Court Ordered Support for Others
State Income Taxes
Mandatory Pension
Health Insurance for Parties' Children
Day Care for Parties' Children
Total Section 6 Monthly Expenses
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
7. Assets Fair Market Value Related Debt Additional Information
Homestead $ $
Other Real Estate $ $
Primary Motor Vehicle $ $
Other Motor Vehicles $ $
Furniture and Appliances $ $
Checking Accounts $ $
Investments $ $
Life Insurance $ $
Business Interests $ $
Pensions $ $
Retirement Accounts $ $
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New Hampshire Financial Affidavit Form
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