N.D. R. Ct. XI app B
As amended through March 18, 2024
STATE OF NORTH DAKOTA
IN DISTRICT COURT
_____ JUDICIAL DISTRICT
COUNTY OF __________________
CIVIL NO.___________________
| A. B., Plaintiff | ) | |
| ) | RULE 8.2, N.D.R.Ct., | |
| vs. | ) | FINANCIAL STATEMENT |
| ) | AND AFFIDAVIT | |
| C. D., Defendant | ) |
Your affiant, being first duly sworn, states as follows:
A. ASSETS.
| 1. I have cash on hand: | |
| 2. I have on deposit in financial institutions: | |
| 3. I have stocks and bonds in the amount of: | |
| 4. Other assets and approximate value are (list): | |
| ITEM | VALUE |
| 5. ______________________ | ___________ |
| 6. ______________________ | ___________ |
| 7. ______________________ | ___________ |
| 8. ______________________ | ___________ |
| 9. ______________________ | ___________ |
| 10. ______________________ | ___________ |
| (Attach additional schedules as needed) | |
| 11. Total Assets | |
| _________________________________________ | |
B. LIABILITIES. CREDITORS UNPAID PAYMENT MONTHLY BALANCE
| 12. ___________________ | ___________ | ___________ |
| 13. ___________________ | ___________ | ___________ |
| 14. ___________________ | ___________ | ___________ |
| 15. ___________________ | ___________ | ___________ |
| 16. ___________________ | ___________ | ___________ |
| 17. ___________________ | ___________ | ___________ |
| (Attach additional schedules as needed) | ||
| 18. Total Liabilities | ||
| ______________________________________ | ||
C. INCOME.
My monthly income, and that of my spouse, is as follows:
| AFFIANT | SPOUSE | |
| 19. Gross Income | ___________ | ___________ |
| 20. Deductions | ___________ | ___________ |
| 21. Federal Tax | ___________ | ___________ |
| 22. FICA | ___________ | ___________ |
| 23. Medicare | ___________ | ___________ |
| 24. State Tax | ||
| 25. Health Insurance | ||
| 26. Retirement | ||
| 27. Savings | ||
| 28. Other | ||
| 29. Total Deductions | ||
| 30. Net Income | ||
| 31. My pay period is every _________________. | ||
| My spouses's pay period is every ______________. | ||
D. EXPENSES.
My current monthly expenses to support myselfand child(ren) are as follows:
| 32. House/Rent Payment | ______________ |
| 33. Gas/Electricity | ______________ |
| 34. Homeowner's/Rent Insurance | ______________ |
| 35. Water | ______________ |
| 36. Telephone | ______________ |
| 37. Cable Television | ______________ |
| 38. Food and Household Items | ______________ |
| 39. Clothing | ______________ |
| 40. Laundry | ______________ |
| 41. Life Insurance | ______________ |
| 42. Automobile Insurance | ______________ |
| 43. Medical Insurance | |
| 44. Transportation | |
| 45. Child Care | |
| 46. School Expenses | |
| 47. Unreimbursed Medical, Dental,Optical | |
| 48. Newspaper and Magazines | |
| 49. Donations | |
| 50.Entertainment | |
| 51. Miscellaneous | |
| 52. TOTAL |
Dated (Month) (Day), (Year).
_________________________
(Affiant)
Subscribed and sworn to before me on (Month) (Day), (Year).
_________________________
Notary Public
N.D. R. Ct. XI app B
Effective 3/1/2000