FAMILY LAW FINANCIAL AFFIDAVIT
($50,000 or more Individual Gross Annual Income)

INSTRUCTIONS FOR FLORIDA FAMILY LAW RULES OF PROCEDURE FORM 12.902(c),  FAMILY LAW FINANCIAL AFFIDAVIT
When should this form be used?

This form should be used when you are involved in a family law case which requires a financial affidavit and your individual gross income is $50,000 OR MORE per year.

This form should be typed or printed in black ink.  After completing this form, you should sign the form before a notary public or deputy clerk.  You should file the original with the clerk of the circuit court in the county where the petition was filed and keep a copy for your records.

What should I do next?

A copy of this form must be mailed or hand delivered to the other party in your case, if it is not served on him or her with your initial papers.  This must be accomplished within 45 days of service of the petition.

Where can I look for more information?

Before proceeding, you should read “General Information for Self-Represented Litigants” found at the beginning of these forms.  The words that are in bold underline in these instructions are defined there.  For further information, see rule 12.285, Florida Family Law Rules of Procedure.

Special notes...

If this is a domestic violence case and you want to keep your address confidential for safety reasons, do not enter the address, telephone, and fax information at the bottom of this form.  Instead, file Petitioner’s Request for Confidential Filing of Address, Florida Supreme Court Approved Family Law Form 12.980(h).

The affidavit must be completed using monthly income and expense amounts.  If you are paid or your bills are due on a schedule which is not monthly, you must convert those amounts.  Hints are provided below for making these conversions.


Hourly - If you are paid by the hour, you may convert your income to monthly as follows:
Hourly amount                 x          Hours worked per week       =           Weekly amount
Weekly amount                x          52 Weeks per year               =           Yearly amount
Yearly amount                 ÷          12 Months per year              =           Monthly Amount
Daily - If you are paid by the day, you may convert your income to monthly as follows:
Daily amount                   x          Days worked per week          =          Weekly amount
Weekly amount                x          52 Weeks per year                =           Yearly amount
Yearly amount                 ÷          12 Months per year               =           Monthly Amount
Weekly - If you are paid by the week, you may convert your income to monthly as follows:
Weekly amount                x          52 Weeks per year                =           Yearly amount
Yearly amount                  ÷         12 Months per year               =           Monthly Amount
Bi-weekly - If you are paid every two weeks, you may convert your income to monthly as follows:
Bi-weekly amount             x                     26                           =           Yearly amount
Yearly amount                  ÷          12 Months per year              =           Monthly Amount
Semi-monthly - If you are paid twice per month, you may convert your income to monthly as follows:
Semi-monthly amount        x                     2                            =            Monthly Amount

Expenses may be converted in the same manner.

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida Family Law Rules of Procedure Form 12.900(a), before he or she helps you.  A nonlawyer helping you fill out these forms also must put his or her name, address, and telephone number on the bottom of the last page of every form he or she helps you complete.

NOTE: You can't save and return to this form online. Be sure to have your state and federal income tax information, a current pay stub, utility bills, insurance, mortgage or rent information, information on child support and alimony, credit card debt and payments, car payments, unemployment and any other income and debt information. You can save the form if it is incomplete, but if you return to the form online, you will have to re-enter your information.

Your full legal name:
I am the: Other Party's legal name:

Your Information
Address:
City, state, zip:
Phone (area code and number):
Fax (area code and number):
Birthdate:

IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR  COUNTY, FLORIDA

,
,
,
Petitioner,

and

.
Respondent.




My Occupation:

I am:
Describe your efforts to find employment, how soon you expect to be employed, and the pay you expect to receive:




Business Address:
City, State Zip Code:
Phone:



Employment Information If you are employed but have a different pay period than the choices given below, or your pay varies (if you have more than one job, for example) estimate your average gross pay as closely as possible and convert it to a monthly pay amount. Enter it here as monthly. If you are self-employed, unemployed, retired, on disability, etc,leave this at 0.

Pay rate $      

Your Gross Monthly pay is $
If this doesn't seem right, please double-check your entry, or calculate your monthly gross wages manually and enter it above as "Monthly".



If you are expecting to become unemployed or change jobs soon, describe the change you expect and why and how it will affect your income:





Date of retirement:
Employer from whom retired:
Address:
City, State Zip: Phone:

LAST YEAR'S GROSS INCOME:
YEAR Your Income:  
Other Party's Income (if known)  






SECTION I. PRESENT MONTHLY GROSS INCOME
Attach extra sheets to your printed form, if needed to cover extra items and descriptions. Items included under "other" should be listed separately with separate dollar amounts. Where you calculate amounts, make sure and use MONTHLY amounts for all the following sections, unless otherwise noted.
The online form makes conversions between other pay periods to monthy, as far as possible.

1. Monthly gross salary or wages 1. $ 0.00
2. Monthly bonuses, commission, allowances, overtime, tips and similar payments 2. $  
3. Monthly business income from sources such as self-employment, partnerships, close corporations, and/or independent contracts (gross receipts minus ordinary and necessary expenses required to produce income) (Attach sheet itemizing such income and expenses.) 3. $  
4. Monthly disability benefits/SSI received 4. $  
5. Monthly Workers' Compensation received 5. $  
6. Monthly Unemployment Compensation received 6. $  
7. Monthly pension, retirement, or annuity payments received 7. $  
8. Monthly Social Security Benefits received 8. $  
9. Monthly Alimony payment actually received
     9a. From this case: $  
     9b. From other case(s): $  
9. $ 0.00
10. Monthly interest and dividends received 10. $
11. Monthly rental income (gross receipts minus ordinary and necessary expenses required to produce income)
(Attach sheet itemizing such income and expense items.)
11. $  
12. Monthly income from royalties, trusts, or estates 12. $  
13. Monthly reimbursed expenses and in-kind payments to the extent that they reduce personal living expenses 13. $  
14. Monthly gains derived from dealing in property (not including nonrecurring gains) 14. $  
15. Any other income of a recurring nature (list source)
15. $  
16. Any other income of a recurring nature (list source)
16. $  
17. PRESENT MONTHLY GROSS INCOME TOTAL: 17.  $ 0.00
SECTION I. PRESENT MONTHLY DEDUCTIONS
18. Federal, state and local income tax (corrected for filing status and allowable dependents and income tax liabilities)
Add up your adjusted tax totals from your current IRS, State and local returns. Do not convert to monthly
$    
a. Filing Status    
b. Number of dependents claimed     
18. $ 0.00 /month
19. FICA or self-employment taxes
Amount listed on your most recent pay stub:  
19. $ 0.00 /month
20. Medicare payments
Amount listed on your most recent pay stub:  
20. $  /month
21. Mandatory union dues
Amount listed on your most recent pay stub:  
21. $ /month
22. Mandatory retirement payments
Amount listed on your most recent pay stub:  
22. $ /month
23. Employer health  insurance payments, including dental insurance. Exclude portion paid for any minor children of this relationship, or insurance not provided by your employer.
Amount listed on your most recent pay stub: 
23. $  /month
24. Monthly court-ordered child support actually paid for children from another relationship 24. $    /month
25. Monthly court-ordered alimony actually paid
     25a. From this case: $    /month
     25b. From other case(s): $    /month
25. $ 0.00  /month
26. TOTAL DEDUCTIONS ALLOWABLE UNDER SECTION 61.30, FLORIDA STATUTES
(Add lines 18 through 25):
26. $
PRESENT NET MONTHLY INCOME : 26. $




SECTION II. AVERAGE MONTHLY EXPENSES
A. HOUSEHOLD:
Mortgage or rent $  
Property taxes $  
House Insurance (if not included in mortgage) $  
Condominium or Homeowner's Association Fees $  
Electricity $  
Water, garbage and sewer $  
Telephone $  
Fuel Oil or natural gas $  
Maintenance/Repairs $  
Lawn care $  
Pool Maintenance $  
Pest control $  
Misc. Household $  
Food $  
Meals outside home $  
Cable or Satellite t.v. $  
Alarm service $  
Service contracts on appliances $  
Maid service $  
Other $  
$  
$  
$  
$  
SUBTOTAL $ 0.00
B. AUTOMOBILE:
Gas $  
Repairs $  
Auto tags and emission testing $  
Insurance $  
Car payments (lease or financing) $  
Car rental/replacement $  
Alternative transportation (bus, rail, car pool, etc) $  
Tolls and parking $  
Other: $  
SUBTOTAL $ 0.00
C. CHILD(REN)'S EXPENSES:
Day Care $  
School tuition $  
School supplies, books and fees $  
After school activities $  
Lunch Money $  
Private lessons or tutoring $  
Allowances $  
Clothing and uniforms $  
Entertainment $  
Health Insurance $  
Medical, dental, prescriptions (nonreimbursed only) $  
Psychiatric/psychological/counselor $  
Orthodontic $  
Vitamins $  
Beauty Shop/Barber Shop $  
Nonprescription medication $  
Cosmetics, toiletries, and sundries $  
Gifts from child(ren) to others (other children, relatives, teachers, etc.) $  
Camp or Summer Activities $  
Clubs (Boy/Girl Scouts, etc.) $  
Access expenses (for nonresidential parent) $  
Miscellaneous $  
SUBTOTAL $ 0.00
MONTHLY EXPENSES FOR CHILD(REN) FROM ANOTHER RELATIONSHIP:(other than court ordered child support)
$  
$  
$  
$  
SUBTOTAL $ 0.00
INSURANCE:
Health insurance, excluding portion paid for any minor child(ren) of the relationship and paycheck deductions $  
Life $  
Dental $  
Other $  
Other $  
SUBTOTAL $ 0.00
E. OTHER EXPENSES NOT LISTED ABOVE:
Dry Cleaning and Laundry $  
Clothing $  
Medical/Dental (uninsured) $  
Psychiatric, psychological or counselor $  
Non-prescription medications, cosmetics toiletries and sundries $  
Grooming $  
Gifts $  
Pet expenses $  
Entertainment $  
Club dues and membership $  
Sports and hobbies $  
Periodicals/books/tapes/CDs $  
Vacations $  
Religious Organizations $  
Bank charges/credit card fees $  
Education expenses $  
Other $  
Other $  
Other $  
Other $  
SUBTOTAL $ 0.00
F. PAYMENTS TO CREDITORS:
Creditor Monthly Payment
 1. $  
 2. $  
 3. $  
 4. $  
 5. $  
 6. $  
 7. $  
 8. $  
 9. $  
 10. $  
 11. $  
 12. $  
 13. $  
SUBTOTAL $ 0.00
TOTAL MONTHLY EXPENSES 28. $ 0.00
SUMMARY
29. TOTAL PRESENT MONTHLY NET INCOME
(from line 27 of SECTION I. INCOME)
29. $ 0.00
30. TOTAL MONTHLY EXPENSES
(from line 28 above)
30. $ 0.00
31. SURPLUS
(if line 29 is more than line 30, subtract line 30 from line 29. This is the amount of your surplus. Enter that amount here.)
31. $ 0.00
32. (DEFICIT)
(if line 29 is less than line 30, subtract line 29 from line 30. This is the amount of your deficit. Enter that amount here.)
$ (0.00)


SECTION III. ASSETS AND LIABILITIES Use the nonmarital column only if this is a petition for dissolution of marriage and you believe an item is "nonmarital," meaning it belongs to only one of you and should not be divided. You should indicate to whom you believe the item(s) or debt belongs. (Typically, you will only use this column if property/debt was owned/owed by one spouse before the marriage. See the “General Information for Self-Represented Litigants” found at the beginning of these forms and section 61.075(1), Florida Statutes, for definitions of “marital” and “nonmarital” assets and liabilities.)

A. ASSETS:
Description of Items. List a description of each separate item owned by you (and/or your spouse, if this is a petition for dissolution of marriage).
DO NOT LIST ACCOUNT NUMBERS.
√ the box next to any asset(s) which you are requesting the judge award to you.
Current Fair Market Value husband (Don't check this column except for separate, non-marital items) wife (Don't check this column except for separate, non-marital items)
$
$
$
$
$
$
$
$
$

$
$
$
$

$
$
$
$
$
$

$
$
$
$
$

$
$
$
$

$
$
$

$
$
$
$
$
$
$

$
$

$
$

$
$

$
$

$
$
$

$
$
$
$
$

$
$
$
$
$
$
$
$
Total Assets $ 0.00


B. LIABILITIES (DEBTS):
Description of items. List a description of each separate item owned by you (and/or your spouse, if this is a petition for dissolution of marriage).
DO NOT LIST ACCOUNT NUMBERS.
√ the box next to any asset(s) which you are requesting the judge award to you.
Current Amount Owed husband (Don't check this column except for separate, non-marital items) wife (Don't check this column except for separate, non-marital items)
$

$

$
$

$
$
$
$
$
$

$
$

$
$
$
$
$
$

$
$

$
  $
  $
  $
  $
  $
  $
Total Debts $ 0.00


C. CONTINGENT ASSETS AND LIABILITIES: INSTRUCTIONS: If you have any POSSIBLE assets (income potential, accrued vacation or sick leave, bonus, inheritance, etc.) or POSSIBLE liabilities (possible lawsuits, future unpaid taxes, contingent tax liabilities, debts assumed by another), you must list them here.
Contingent Assets

√ the box next to any asset(s) which you are requesting the judge award to you.
Possible Value husband(Don't check this column except for separate, non-marital items) wife(Don't check this column except for separate, non-marital items)
  $
  $
  $
  $
  $
Total contingent Assets $ 0.00


Contingent Liabilities

√ the box next to any asset(s) which you believe you should be responsible.
Possible Amount Owed husband(Don't check this column except for separate, non-marital items) wife(Don't check this column except for separate, non-marital items)
  $
  $
  $
  $
  $
Total contingent Liabilities $ 0.00



SECTION IV. CHILD SUPPORT GUIDELINES WORKSHEET
(Florida Family Law Rules of Procedure Form 12.902(e), Child Support Guidelines Worksheet, MUST be filed with the court at or prior to a hearing to establish or modify child support. This requirement cannot be waived by the parties.)




I certify that a copy of this document was
to the person(s) listed below on {date}.

Other party or his/her attorney:
Name:
Address:
City, State, Zip:
Fax Number:

I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this notice and that the punishment for knowingly making a false statement includes fines and/or imprisonment.

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW: [fill in all blanks]

full legal name of Non-Lawyer
Street:
City:
State:
Phone:

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