Financial Affidavit Template

This Financial Affidavit (the “Affidavit”) is made on [Date] by:

Affiant: [Full Name], date of birth: [DOB], address: [Address], phone/email: [Contact].

Case (Optional): [Court/County] | Case No.: [__]
Other Party (Optional): [Name]

1. Household and Dependents

1.1 Marital Status: ☐ Married ☐ Separated ☐ Divorced ☐ Single.
1.2 Dependents/Children:

• [Name], age [], relationship []

• [Name], age [], relationship []

1.3 Housing: ☐ Rent ☐ Own ☐ Live with family ☐ Other: [Explain].

2. Employment and Income

2.1 Employer: [Company] | Position: [Title] | Start date: [Date].
2.2 Pay Frequency: ☐ Weekly ☐ Biweekly ☐ Monthly.
2.3 Gross Income: $[] per pay period.
2.4 Net Income (Take-Home): $[] per pay period.
2.5 Other Income:

• Bonuses/commissions: $[__]/year (est.)

• Self-employment: $[__]/month

• Benefits (unemployment/disability): $[__]/month

• Rental income: $[__]/month

• Other: [List]

3. Monthly Living Expenses

3.1 Housing: Rent/mortgage $[] | Property tax/HOA $[] | Insurance $[].
3.2 Utilities: Electric $[] | Gas $[] | Water $[] | Internet $[] | Phone $[].
3.3 Food/Household: Groceries $[] | Household supplies $[].
3.4 Transportation: Car payment $[] | Fuel $[] | Insurance $[] | Public transit $[].
3.5 Medical: Health insurance $[] | Out-of-pocket $[] | Prescriptions $[].
3.6 Child-Related (If Any): Childcare $[] | School costs $[] | Activities $[].
3.7 Debt Payments: Credit cards $[] | Loans $[] | Other $[__].
3.8 Other Expenses: [List + amounts].
3.9 Total Monthly Expenses (Estimate): $[Total].

4. Assets

4.1 Cash/Bank Accounts:

• Bank: [Name], account type: [Checking/Savings], last 4 digits: [____], balance: $[__]

• Bank: [Name], account type: [Checking/Savings], last 4 digits: [____], balance: $[__]

4.2 Real Estate:

• Address: [], estimated value: $[], mortgage balance: $[], monthly payment: $[]

4.3 Vehicles:

• [Year/Make/Model], value: $[], loan balance: $[]

4.4 Retirement/Investments:

• [401(k)/IRA/Brokerage], institution: [], balance: $[]

4.5 Other Assets:

• Business interest: [], estimated value: $[]

• Personal property (jewelry, collections): [], estimated value: $[]

• Other: [List]

5. Debts and Liabilities

5.1 Credit Cards:

• Creditor: [], balance: $[], minimum payment: $[__]

5.2 Loans:

• Student loan: [], balance: $[]

• Personal loan: [], balance: $[]

• Auto loan: [], balance: $[]

• Other: [List]

5.3 Other Liabilities: Taxes owed: $[] | Judgments/collections: $[] | Other: [List].

6. Insurance (Optional)

6.1 Health insurance: [Provider]
6.2 Life insurance: [Provider + beneficiary]
6.3 Home/renter’s insurance: [Provider]
6.4 Auto insurance: [Provider]

7. Supporting Documents (Attach as Available)

7.1 ☐ Pay stubs (last [])
7.2 ☐ Tax returns (last [] years)
7.3 ☐ Bank statements (last [] months)
7.4 ☐ Credit card statements (last [] months)
7.5 ☐ Mortgage/loan statements
7.6 ☐ Proof of childcare/medical expenses
7.7 ☐ Other: [List]

8. Statement Under Oath

8.1 I declare under penalty of perjury that the information in this Financial Affidavit is true and correct to the best of my knowledge.

Signatures

Affiant: [Full Name]
Date: [Date]
Signature: ___________________________

Witnesses (If Required)

Witness Name: [Name]
Date: [Date]
Signature: ___________________________

Notary / Notarization (If Required)

State of [State]
County of [County]

On [Date], before me, [Notary Name], personally appeared [Affiant Full Name], known to me (or satisfactorily proven) to be the person whose name is subscribed to this Affidavit, and acknowledged that they executed it for the purposes stated.

Notary Public Signature: _______________________
My Commission Expires: _______________________
Notary Seal (if applicable): ___________________