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THE STATE OF NEW HAMPSHIRE
JUDICIAL BRANCH
http://www.courts.state.nh.us

Court Name:
Case Name:
Case Number:
(if known)

FINANCIAL AFFIDAVIT
1. General Information
Name
Street Address
Town/City, State, Zip
Mailing Address, if different
Date of Birth
Social Security Number
Highest Grade or Degree Completed
Date of Marriage
Date of Separation or Divorce

4. Monthly Income - Miscellaneous
AFDC, TANF, and Food Stamps
Other Public Assistance
Children's Income
Child Support

2. Children born to, or adopted by, the Parties (Full Name, DOB, and SSN)

2a. Number of people currently living in household including self:
3. Employment Information
Name, Address, and Phone Number of Employer

5. Monthly Income Before Taxes
Base Pay from Salary, Wages
Overtime and Shift Differential
Commissions, Tips, Bonuses
Part-time Employment
Self-employment
Unemployment and Veteran's Benefits
Disability, Workers' Compensation
Pension and Retirement Benefits
Social Security Benefits (SSA)
Interest and