Fill in a Valid Florida Financial Affidavit Short 12.902(b) Form

Hourly - If you are paid by the hour, you may convert your income to monthly as follows:

Daily - If you are paid by the day, you may convert your income to monthly as follows:

Weekly - If you are paid by the week, you may convert your income to monthly as follows:

Bi-weekly - If you are paid every two weeks, you may convert your income to monthly as follows:

Semi-monthly - If you are paid twice per month, you may convert your income to monthly as follows:

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.

Instructions to Florida Family Law Rules of Procedure Form 12.902(b), Family Law Financial Affidavit (Short Form) (01/15)

required to produce income) (Attach sheet itemizing such income and expense items.)

12._______ Monthly income from royalties, trusts, or estates

13._______ Monthly reimbursed expenses and in-kind payments to the extent that they reduce personal living expenses

14._______ Monthly gains derived from dealing in property (not including nonrecurring gains)

15._______ Any other income of a recurring nature (list source) _________________________

16.__________________________________________________________________________

17.$ _______ TOTAL PRESENT MONTHLY GROSS INCOME (Add lines 1–16)

PRESENT MONTHLY DEDUCTIONS:

18.$______Monthly federal, state, and local income tax (corrected for filing status and allowable dependents and income tax liabilities)

a.Filing Status ____________

b.Number of dependents claimed _______

19._______ Monthly FICA or self-employment taxes

20._______ Monthly Medicare payments

21._______ Monthly mandatory union dues

22._______ Monthly mandatory retirement payments

23._______ Monthly health insurance payments (including dental insurance), excluding portion paid for any minor children of this relationship

24._______ Monthly court-ordered child support actually paid for children from another relationship

25._______Monthly court-ordered alimony actually paid (Add 25a and 25b)

25a. from this case: $ _______

25b. from other case(s):$ _______

26.$_______ TOTAL DEDUCTIONS ALLOWABLE UNDER SECTION 61.30, FLORIDA STATUTES (Add lines 18 through 25).

27.$_______ PRESENT NET MONTHLY INCOME (Subtract line 26 from line 17)

Florida Family Law Rules of Procedure Form 12.902(b), Family Law Financial Affidavit (Short Form)(01/15)

28. $_______ TOTAL MONTHLY EXPENSES (add ALL monthly amounts in A through F above)

SUMMARY

29.$_______ TOTAL PRESENT MONTHLY NET INCOME (from line 27 of SECTION I. INCOME)

30.$_______ TOTAL MONTHLY EXPENSES (from line 28 above)

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.)

32.($_______) (DEFICIT) (If line 30 is more than line 29, subtract line 29 from line 30. This is the amount of your deficit. Enter that amount here.)

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:

Florida Family Law Rules of Procedure Form 12.902(b), Family Law Financial Affidavit (Short Form) (01/15)

B. LIABILITIES:

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.

Florida Family Law Rules of Procedure Form 12.902(b), Family Law Financial Affidavit (Short Form) (01/15)

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.)

[Check one only]

____ A Child Support Guidelines Worksheet IS or WILL BE filed in this case. This case involves the

establishment or modification of child support.

____ A Child Support Guidelines Worksheet IS NOT being filed in this case. The establishment or

modification of child support is not an issue in this case.

I certify that a copy of this document was [check all used]: ( ) e-mailed ( ) mailed ( ) faxed

( ) hand delivered to the person(s) listed below on {date} ________________________________.

Other party or his/her attorney:

Name: _____________________________

Address: ____________________________

City, State, Zip: _______________________

Fax Number: _________________________

E-mail Address(es): _____________________

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

Dated:

Signature of Party

Printed Name: ________________________________

Address: ___________________________________

City, State, Zip: ______________________________

Fax Number: ________________________________

E-mail Address(es): ____________________________

STATE OF FLORIDA

COUNTY OF

Florida Family Law Rules of Procedure Form 12.902(b), Family Law Financial Affidavit (Short Form) (01/15)

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:

Florida Family Law Rules of Procedure Form 12.902(b), Family Law Financial Affidavit (Short Form) (01/15)