Financial Disclosure Affidavit Instructions

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This form contains 114 fields organized into 33 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name Type Description
Additional Child Support Orders (Yes/No and Details)
Additional Child Support Amount Number
Enter the amount of any additional child support you are paying under other child support orders. Fill only if 'Yes (paying additional child support orders)' is 'Yes'.
Depends on: Yes (paying additional child support orders)
Recipient of Additional Child Support Text
Enter the name of the person or agency to whom you pay the additional child support. Fill only if 'Yes (paying additional child support orders)' is 'Yes'.
Depends on: Yes (paying additional child support orders)
Yes (paying additional child support orders) Checkbox
Check this box if you are currently paying any additional child support orders besides the one in this case.
No (not paying additional child support orders) Checkbox
Check this box if you are not currently paying any additional child support orders.
Affirmation Date
Affirmation Month Text
Enter the month in which you are signing this affirmation.
Affirmation Year Text
Enter the year in which you are signing this affirmation.
Affirmation date (day of month) Checkbox
Fill in this box with the day of the month on which you are signing and affirming the statement.
Automobile
Vehicle Year Number
Enter the model year of the automobile.
Vehicle Model Text
Enter the automobile's model name (e.g., Camry, Civic).
Vehicle Value Number
Enter the current estimated value of the automobile in dollars.
Vehicle Make Text
Enter the automobile's manufacturer (e.g., Toyota, Honda).
Checking Account
Checking account bank name Text
Enter the name of the bank or credit union where your checking account is held.
Checking account balance Number
Enter the current balance of your checking account in dollars.
Child & Education Expenses
Child Care Monthly Expense Number
Enter your total monthly amount paid for child care.
School Tuition & Education Expenses Monthly Expense Number
Enter your total monthly amount paid for school tuition and other education-related expenses.
Child Care Details
Child Care Cost Frequency Text
Enter the time period the child care cost amount applies to (for example, per hour, per day, or per week).
Child Care Provider Name Text
Enter the name of your child care provider.
Child Care Cost Amount Number
Enter the amount you pay for child care.
choicebutton_1_37_de4aeb01 CheckBox
Child(ren) Health Insurance Coverage
Other Health Insurance Coverage Description Text
Provide details of the child(ren)'s health insurance coverage if it is covered by something other than the listed options (e.g., name of the plan or program). Fill only if 'Other (specify)' is 'Yes'.
Depends on: Other (specify)
Other (specify) Checkbox
Check this box if the child(ren)'s health insurance is covered by a source other than Medicaid, your plan, the other parent's plan, or Child Health Plus, and specify the coverage type/provider on the line provided.
Medicaid Checkbox
Check this box if the child(ren)'s health insurance coverage is provided through Medicaid.
My plan Checkbox
Check this box if the child(ren) are covered under your health insurance plan.
The other parent's plan Checkbox
Check this box if the child(ren) are covered under the other parent's health insurance plan.
Child Health Plus Checkbox
Check this box if the child(ren)'s health insurance coverage is provided through Child Health Plus.
Court and Case Identifiers
Docket Number Text
Enter the docket number assigned to this case.
File Number Text
Enter the court file number assigned to this case.
Court Date, Time, and Part Text
Enter the scheduled court appearance date and time and the assigned part/room for this matter.
Court / County Text
Enter the name of the court and county where this support proceeding is filed.
Employment Details
Employer Name Text
Enter the name of your current employer.
Hours Worked Per Week Text
Enter the number of hours you work per week at this job.
Employer Address Text
Enter the street address of your employer.
Yes (self-employed) Checkbox
Check this box if you are self-employed.
No (not self-employed) Checkbox
Check this box if you are not self-employed.
First Loan/Debt Entry
Current Balance Owed Number
Enter the current total balance owed on this debt.
Debt Purpose/Type Text
Describe what the debt is for (for example, car loan, credit card, medical bill, or personal loan).
Creditor/Lender Name Text
Enter the name of the person, company, or agency to whom this debt is owed.
Payment Amount Number
Enter the amount you pay toward this debt each payment period.
Monthly Checkbox
Check this box if the payment amount for this first loan/debt is paid monthly.
Weekly Checkbox
Check this box if the payment amount for this first loan/debt is paid weekly.
First Other Income Row
Other Income Payment Frequency Text
Enter the time period for this other income amount (for example, per week, per month, or per year).
Other Income Source Text
Enter the source of this other income (such as public assistance, unemployment benefits, workers’ compensation, SSD/SSI, pension, rent, tips, or investment income).
choicebutton_0_32_504c7130 CheckBox
Health Insurance Coverage Included
Dental Checkbox
Check this box if your health insurance plan includes dental coverage. Fill only if 'I don't have health insurance coverage' is 'No'.
Depends on: I don't have health insurance coverage
Vision Checkbox
Check this box if your health insurance plan includes vision coverage. Fill only if 'I don't have health insurance coverage' is 'No'.
Depends on: I don't have health insurance coverage
Prescription Checkbox
Check this box if your health insurance plan includes prescription drug coverage. Fill only if 'I don't have health insurance coverage' is 'No'.
Depends on: I don't have health insurance coverage
Medical Checkbox
Check this box if your health insurance plan includes medical coverage. Fill only if 'I don't have health insurance coverage' is 'No'.
Depends on: I don't have health insurance coverage
Health Insurance Coverage Type
I don't have health insurance coverage Checkbox
Check this box if you currently do not have any health insurance coverage.
Through my job Checkbox
Check this box if your health insurance coverage is provided through your employment.
Medicare Checkbox
Check this box if your health insurance coverage is through Medicare.
Privately purchased Checkbox
Check this box if you buy your health insurance directly from an insurer or marketplace (not through an employer or public program).
Medicaid Checkbox
Check this box if your health insurance coverage is through Medicaid.
Health Insurance Plan Details
Health Insurance Coverage and Cost Details Text
Enter the details of your health insurance coverage, including the plan/provider information and the cost.
Other Documents Related to Income Text
Describe any other documents you will bring that show or verify your income.
Other Documents Related to Financial Information Text
Describe any other documents you will bring that support your financial information beyond pay stubs and tax forms.
Health Insurance Premium Costs
Family Plan Premium Payment Period Text
Enter the time period the stated Family Plan premium cost covers (for example, per week, per month, or per year). Fill only if 'I don't have health insurance coverage' is 'No'.
Depends on: I don't have health insurance coverage
Individual Plan Premium Payment Period Text
Enter the time period the stated Individual Plan premium cost covers (for example, per week, per month, or per year). Fill only if 'I don't have health insurance coverage' is 'No'.
Depends on: I don't have health insurance coverage
Individual Plan premium cost Checkbox
Check this box if you pay for an Individual Plan and are providing the cost of your health insurance for an individual plan on this line. Fill only if 'I don't have health insurance coverage' is 'No'.
Depends on: I don't have health insurance coverage
Family Plan premium cost Checkbox
Check this box if you pay for a Family Plan and are providing the cost of your health insurance for a family plan on this line. Fill only if 'I don't have health insurance coverage' is 'No'.
Depends on: I don't have health insurance coverage
House/Apt Owned
Mortgage Balance Number
Enter the current amount owed on the mortgage for the owned house or apartment.
Market Value Number
Enter the current estimated market value of the owned house or apartment.
House/Apt Address Text
Enter the full street address of the house or apartment that is owned.
Housing Expense
Monthly Rent or Mortgage Number
Enter the total amount you pay each month for rent or your mortgage.
Insurance Expenses
Home/Fire Insurance Monthly Cost Number
Enter your total monthly cost for home or fire insurance.
Auto Insurance Monthly Cost Number
Enter your total monthly cost for auto insurance.
Other Insurance Monthly Cost Number
Enter the total monthly cost for the other insurance type listed.
Life Insurance Monthly Cost Number
Enter your total monthly cost for life insurance.
Other Insurance Type Text
Specify the type of other insurance you pay for each month. Fill only if 'Other Insurance Monthly Cost' is greater than $0.
Depends on: Other Insurance Monthly Cost
Health Insurance Monthly Cost Number
Enter your total monthly cost for health insurance. Fill only if 'I don't have health insurance coverage' is 'No'.
Depends on: I don't have health insurance coverage
Other Assets (First Item)
Other Asset Details (Item 1) Text
Describe the first other asset you own (for example, other real estate, car, boat, snowmobile, stocks, or bonds).
Other Asset Value (Item 1) Number
Enter the current dollar value of the first other asset listed.
Other Assets (Second Item)
Other Asset (Second) Value Number
Enter the estimated current dollar value of the second other asset.
Other Asset (Second) Details Text
Enter a description of the second other asset (e.g., type of asset and identifying details such as account number, property description, or vehicle information).
Other Expense Description
Other Utilities Expense Description Text
Enter a brief description of the other monthly utility expense. Fill only if 'Other utilities expense' is greater than $0.
Depends on: Other utilities expense
Other Household Members and Their Income
Other Household Members' Total Income Amount Number
Enter the total income amount received from other household members. Fill only if 'How many people are in your household? Me + _______ others' is greater than 0.
Other Household Members' Income Frequency Text
Enter the time period that the other household members' income amount covers (for example, per week or per month). Fill only if 'How many people are in your household? Me + _______ others' is greater than 0.
Number of Other Household Members Text
Enter how many other people live in your household in addition to you.
Party Name and Residence Address
Residence Street Address Text
Enter the street address where you currently reside.
Party Full Name Text
Enter the full legal name of the party completing this form (petitioner or respondent).
Residence City, State, and ZIP Text
Enter the city, state, and ZIP code for your current residence address.
Personal & Household Expenses
Food expense (monthly) Number
Enter your total monthly cost for food and groceries.
Clothing expense (monthly) Number
Enter your total monthly spending on clothing and related items.
Contributions expense (monthly) Number
Enter your total monthly amount for contributions such as charitable donations or similar regular contributions.
Medical/Dental/Prescription expense (monthly) Number
Enter your total monthly out-of-pocket costs for medical care, dental care, and prescription medications.
Primary Job Income
Gross income pay period Text
Enter the time period that the gross income amount is based on (for example, per week, per two weeks, or per month).
Gross income amount Number
Enter your gross income from all jobs for the pay period indicated.
Take-home income amount Number
Enter your take-home (net) income from all jobs for the pay period indicated.
Take-home income pay period Text
Enter the time period that the take-home income amount is based on (for example, per week, per two weeks, or per month).
Savings Account
Savings Account Bank Name Text
Enter the name of the bank or financial institution where the savings account is held.
Savings Account Balance Number
Enter the current dollar balance in the savings account.
Second Loan/Debt Entry
Balance Owed (Second Debt) Number
Enter the current outstanding balance you still owe for this second debt.
Purpose of Debt (Second Debt) Text
Describe what this second debt is for (for example, car loan, credit card, or personal loan).
Payment Amount (Second Debt) Number
Enter the amount you pay each payment period for this second debt.
Owed To (Second Debt) Text
Enter the name of the person, company, or lender that you owe this second debt to.
Weekly Checkbox
Check this box if the payment amount for the second loan/debt is paid weekly.
Monthly Checkbox
Check this box if the payment amount for the second loan/debt is paid monthly.
Second Other Income Row
Other Income 2 Frequency Text
Enter how often you receive this second other-income amount (for example, weekly, biweekly, monthly, or yearly).
Other Income 2 Source Text
Enter the source of this second other income (such as public assistance, SNAP, unemployment, SSI, pension, tips, rent, or other).
Other income entry (row 2) Checkbox
Check this box if you need to report a second “Other income” item (enter the amount/per and the income source on the second line).
Signature & Printed Name
Printed or Typed Name Text
Enter your full name as it should appear in print to identify the person signing this form.
Signature Text
Enter your signature to certify that the statements in this form are true.
Third Other Income Row
Other Income Amount (Row 3) Number
Enter the dollar amount you receive from this third other income source.
Other Income Source (Row 3) Text
Describe the source of this third other income (for example, public assistance, SNAP, tips, unemployment, workers’ compensation, SSI/SSD, pension, investment income, etc.).
Other income (third entry) Checkbox
Check this box if you need to provide a third “Other income” item (amount and source) on the third line in the Other income section.
Total Monthly Expenses
Total monthly expenses Number
Enter the total amount of all your monthly expenses listed in this section. Fill only if 'Home/Fire Insurance Monthly Cost', 'Auto Insurance Monthly Cost', 'Gasoline Amount', 'Electric utilities expense', 'Public Transportation Amount', 'Phone/TV/Internet utilities expense', 'Other utilities expense', 'Other Insurance Monthly Cost', 'Monthly Rent or Mortgage', 'Auto Payment Amount', 'Life Insurance Monthly Cost', 'Gas utilities expense', 'Child Care Monthly Expense', 'School Tuition & Education Expenses Monthly Expense', 'Other Transportation Expense Amount', 'Food expense (monthly)', 'Health Insurance Monthly Cost', 'Clothing expense (monthly)', 'Contributions expense (monthly)', 'Medical/Dental/Prescription expense (monthly)' are filled (all).
Depends on: Monthly Rent or Mortgage, Gas utilities expense, Phone/TV/Internet utilities expense, Electric utilities expense, Other utilities expense, Child Care Monthly Expense, School Tuition & Education Expenses Monthly Expense, Food expense (monthly), Clothing expense (monthly), Medical/Dental/Prescription expense (monthly), Contributions expense (monthly), Health Insurance Monthly Cost, Life Insurance Monthly Cost, Auto Insurance Monthly Cost, Home/Fire Insurance Monthly Cost, Other Insurance Monthly Cost, Auto Payment Amount, Gasoline Amount, Public Transportation Amount, Other Transportation Expense Amount
Transportation Expenses
Gasoline Amount Number
Enter your monthly gasoline expense amount.
Public Transportation Amount Number
Enter your monthly public transportation expense amount.
Auto Payment Amount Number
Enter your monthly auto loan or lease payment amount.
Other Transportation Expense Description Text
Describe any other monthly transportation expense not listed above. Fill only if 'Other Transportation Expense Amount' is greater than $0.
Depends on: Other Transportation Expense Amount
Other Transportation Expense Amount Number
Enter the monthly amount for the other transportation expense described.
Utilities Expenses
Electric utilities expense Number
Enter your monthly amount paid for electric utility service.
Phone/TV/Internet utilities expense Number
Enter your total monthly amount paid for phone, TV, and internet services.
Other utilities expense Number
Enter your monthly amount paid for any other utility not listed above.
Gas utilities expense Number
Enter your monthly amount paid for gas utility service.