FINANCIAL AFFIDAVIT - Connecticut
FINANCIAL AFFIDAVIT
Applicant: ___________________________________
I. GROSS ANNUAL INCOME
A. Principal Employment $ ______________
Deductions:
Federal Taxes ______________
FICA/Medicare ______________
CT Taxes ______________
Other:
_______________ ______________
_______________ ______________
Total: $ _____________
Net Annual Income from Principal Employment $ _____________
B. Other Income
Sources of Income, e.g.,
Dividends, Interest ______________
______________
Deductions: ______________
Total: ______________
Net Annual Other Income $ ____________
TOTAL ANNUAL NET INCOME: $ ____________
II. ANNUAL EXPENSES
A. Mortgage(s) or Home Equity Line(s) of Credit $ ____________
B. Real Estate Taxes $ ____________
C. Insurance Premiums:
Medical/Dental _____________
Automobile _____________
Homeowners _____________
Total: $ ____________
D. Medical and Dental Expenses $ ____________
E. Child Support $ ____________
F. Alimony $ ____________
G. Day Care $ ____________
H. Other: _____________
_____________
_____________
_____________ $ ____________
TOTAL ANNUAL EXPENSES: $ ____________
LIABILITIES (include joint and several obligations)
A. Creditor Amt. Debt Bal. Due Annual Pmt.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
TOTAL LIABILITIES: $ __________ $ __________
IV. ASSETS (include individual and jointly held)
A. Real Estate
Home: Address _____________________________
_____________________________
Value: $ ______________
Mortgage: $ ______________
Equity: $ ______________
Other: Address _____________________________
_____________________________
Value: $ ______________
Mortgage: $ ______________
Equity: $ ______________
B. Bank Accounts
Bank Type of Account Value
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
$_______________
C. Stocks, Bonds, Mutual Funds
Company Number of Shares Value
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
$_______________
D. Deferred Compensation Plans
Name of Plan Approximate Value
________________________________________________________________
________________________________________________________________
________________________________________________________________
$_______________
E. All Other Assets Approximate Value
________________________________________________________________
________________________________________________________________
________________________________________________________________
$_______________
TOTAL CASH VALUE OF ALL ASSETS: $ _______________
SUMMARY
TOTAL ANNUAL NET INCOME $ ______________
TOTAL ANNUAL EXPENSES (II AND III) $ ______________
TOTAL CASH VALUE OF ASSETS $ ______________
TOTAL BALANCE LIABILITIES (III) $_______________
CERTIFICATION
I hereby certify that the foregoing statement is true and accurate to the best of my knowledge and belief.
________________________________
Subscribed and sworn to before me this ________ day of __________________, _____.
________________________________
Commissioner of the Superior Court
Notary Public
My Commission Expires:
................
................
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