Appendix B. Financial Statement And Affidavit

STATE OF NORTH DAKOTA IN DISTRICT COURT COUNTY OF _____________ ____ JUDICIAL DISTRICT Civil No. A.B., Plaintiff ) RULE 8.2, N.D.R.Ct., vs. ) FINANCIAL STATEMENT C.D., Defendant ) AND AFFIDAVIT Your affiant, being first duly sworn, states as follows: A. ASSETS. 1. I have cash on hand: $_________ 2. I have on deposit in financial institutions: $_________ 3. I have stocks and bonds in the amount of: $_________ 4. Other assets and approximate value are (list): ITEM VALUE IN POSSESSION OF 5. ______________________ ___________ _______________ 6. ______________________ ___________ _______________ 7. ______________________ ___________ _______________ 8. ______________________ ___________ _______________ 9. ______________________ ___________ _______________ 10. ______________________ ___________ _______________ (Attach additional schedules as needed) 11. Total Assets _________________________________________ B. LIABILITIES. CREDITORS UNPAID PAYMENT MONTHLY BALANCE 12. ___________________ ___________ _______________ 13. ___________________ ___________ _______________ 14. ___________________ ___________ _______________ 15. ___________________ ___________ _______________ 16. ___________________ ___________ _______________ 17. ___________________ ___________ _______________ (Attach additional schedules as needed) 18. Total Liabilities ______________________________________ C. INCOME. My monthly income, and that of my spouse, is as follows: AFFIANT SPOUSE 19. Gross Income _______ _______ 20. Deductions _______ _______ 21. Federal Tax _______ _______ 22. FICA _______ _______ 23. Medicare _______ _______ 24. State Tax _______ _______ 25. Health Insurance _______ _______ 26. Retirement _______ _______ 27. Savings _______ _______ 28. Other _______ _______ 29. Total Deductions _______ _______ 30. Net Income _______ _______ 31. My pay period is every _________________. My spouses's pay period is every ______________. D. EXPENSES. My current monthly expenses to support myselfand child(ren) are as follows: 32. House/Rent Payment ______________ 33. Gas/Electricity ______________ 34. Homeowner's/Rent Insurance ______________ 35. Water ______________ 36. Telephone ______________ 37. Cable Television ______________ 38. Food and Household Items . ______________ 39. Clothing ______________ 40. Laundry ______________ 41. Life Insurance ______________ 42. Automobile Insurance ______________ 43. Medical Insurance ______________ 44. Transportation ______________ 45. Child Care ______________ 46. School Expenses ______________ 47. Unreimbursed Medical, Dental,Optical ______________ 48. Newspaper and Magazines ______________ 49. Donations ______________ 50.Entertainment ______________ 51. Miscellaneous ______________ 52. TOTAL ______________ Dated (Month) (Day), (Year). _________________________ (Affiant) Subscribed and sworn to before me on (Month) (Day), (Year). _________________________ Notary Public