Professional Documents
Culture Documents
SECTION I. INCOME
1. My age is: 45
2. My Occupation is: Communications Consultant
3. I am currently [ X all that apply]
a. Unemployed
Describe your efforts to find employment, how soon you expect to be employed, and the pay you expect to receive.
Check here if you currently have more than one job. List the information above for the second job(s)
on a separate sheet and attach it to this affidavit.
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Florida Family Law Rules of Procedure Form 12.902(c), Family Law Financial Affidavit (01/15)
c. Retired.
Date of Retirement :
Employer from whom retired :
Address :
City, State and Zipcode :
Telephone Number :
LAST YEAR'S GROSS INCOME: Your Income Other Party's (If Known)
$ $563,518 $ Unknown
Year Income was generated : 2018 2018
SECTION I. PRESENT MONTHLY GROSS INCOME:
Footnote No.
1. $ 0.00 Monthly gross salary or wages
2. 0.00 Monthly bonuses, commissions, allowances, overtime, tips, and similar payments
Florida Family Law Rules of Procedure Form 12.902(c), Family Law Financial Affidavit (01/15) Page 2
17.$ 23,956.00 PRESENT MONTHLY GROSS INCOME (From prior Page)
27. $ 16,594.99 PRESENT NET MONTHLY INCOME (Subtract line 26 from line 17)
* This amount includes Federal income tax , Virginia state tax and local business tax.
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Florida Family Law Rules of Procedure Form 12.902(c), Family Law Financial Affidavit (01/15)
SECTION II. AVERAGE MONTHLY EXPENSES
Proposed/Estimated Expenses. If this is a dissolution of marriage case and your expenses as listed below do not reflect what you
actually pay currently, you should write "estimate" next to each amount that is estimated.
HOUSEHOLD
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Florida Family Law Rules of Procedure Form 12.902(c), Family Law Financial Affidavit (01/15)
SECTION II. AVERAGE MONTHLY EXPENSES
Proposed/Estimated Expenses. If this is a dissolution of marriage case and your expenses as listed below do not reflect what you
actually pay currently, you should write "estimate" next to each amount that is estimated.
AUTOMOBILE
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Florida Family Law Rules of Procedure Form 12.902(c), Family Law Financial Affidavit (01/15)
SECTION II. AVERAGE MONTHLY EXPENSES
Proposed/Estimated Expenses. If this is a dissolution of marriage case and your expenses as listed below do not reflect what you
actually pay currently, you should write "estimate" next to each amount that is estimated.
61. 0.00
School Supplies and Books, Fees
62. 0.00
After School Activities
63. 0.00
Lunch Money
64. 0.00
Private Lessons / Tutoring
65. 0.00
Allowance
66. 0.00
Clothing / Uniforms
67. 0.00
Entertainment-Movies, Parties, Etc
68. 0.00
Health Insurance
69. 0.00 Medical, Dental, Prescriptions
70. 0.00 Psychiatric/Psychological/Counselor
71. 0.00 Vitamins
72. 0.00 Beauty Parlor/Barbershop
73. 0.00 Non-Prescription Medication (NR)
74. 0.00 Cosmetics/Toiletries and Sundries
75. 0.00 Gifts From Children to Others
76. 0.00 Vacation
77. 0.00 Camp or/and Other Summer Activities
78. 0.00 Clubs ( Boy/Girl Scouts, Etc)
79. 0.00 Time-Sharing Expense-Non-Res Parent
80. 0.00 Orthodontic
81. 0.00 Miscellaneous
82. 930.00 Other Expenses
83. 3,403.00 SUBTOTAL (add lines 59 through 82)
INSURANCE
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Florida Family Law Rules of Procedure Form 12.902(c), Family Law Financial Affidavit (01/15)
SECTION II. AVERAGE MONTHLY EXPENSES
Proposed/Estimated Expenses. If this is a dissolution of marriage case and your expenses as listed below do not reflect what you
actually pay currently, you should write "estimate" next to each amount that is estimated.
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Florida Family Law Rules of Procedure Form 12.902(c), Family Law Financial Affidavit (01/15)
SECTION II. AVERAGE MONTHLY EXPENSES
Proposed/Estimated Expenses. If this is a dissolution of marriage case and your expenses as listed below do not reflect what you
actually pay currently, you should write "estimate" next to each amount that is estimated.
PAYMENTS TO CREDITORS
SUMMARY
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Florida Family Law Rules of Procedure Form 12.902(c), Family Law Financial Affidavit (01/15)
SECTION III. ASSETS AND LIABILITIES
The box next to each description is checked with an X if any portion of the value is shown as going to this party on his/her
equitable distribution workscreen and indicates that he/she desires some or all of that asset or liability.
Use the nonmarital column only if this is a petition for dissolution of marriage and you believe an item is all or part "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
A. ASSETS: Nonmarital
DESCRIPTION OF ITEM(S). List a description of each item owned by Current Fair ( x Correct Column)
you (and/or your spouse, if this is a petition for dissolution of marriage). FNN Market Value J. A.
Cash On Hand and In Banks
Cash 0
X Suntrust Personal Checking 0700 1 1,988 X
X Suntrust Business Checking 2436 2 8,694 X
Totals 10,682
Stocks and Bonds
Stock 0
Totals 0
Real Estate Assets
X 2305 Lincoln St. 23 761,300 X
Totals 761,300
Business Interests
RevUp Software 0 X
SHW Partners LLC UNK 0 X
Totals 0
Transportation Assets
Automobile 0
Totals 0
Retirement Assets
Retirement Plan 0
John Hancock Teneo Holdings 401(k) Plan 3 0 X
X Wells Fargo Advisors 1901 4 27 X
Ingham Retirement 5 0 X
Vanguard Retirement 6 0 X
X Metropolitan Life SC Optional Retirement Program 7 6,828 X
Totals 6,855
Florida Family Law Rules of Procedure Form 12.902(c), Family Law Financial Affidavit (01/15)
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A. ASSETS: Nonmarital
DESCRIPTION OF ITEM(S). List a description of each item owned by Current Fair ( x Correct Column)
you (and/or your spouse, if this is a petition for dissolution of marriage). FNN Market Value J. A.
Insurance Assets
Life Insurance 0
Totals 0
Furniture and Fixtures Assets
Furniture 0
Totals 0
Tangible Other Assets
Other Tangible 0
X Baseball Card Collection 22 10,000 X
Totals 10,000
Miscellaneous Assets
Miscellaneous 0
Totals 0
Total Assets 788,837
Florida Family Law Rules of Procedure Form 12.902(c), Family Law Financial Affidavit (01/15)
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Nonmarital
B. LIABILITIES:
Current Fair ( x Correct Column)
DESCRIPTION OF ITEM(S). List a description of each item owed by
you (and/or your spouse, if this is a petition for dissolution of marriage). FNN Market Value J. A.
X TCS 8 7,480 X
X American Express 3004 9 10,200 X
X SunTrust LightStream Loan 5544 10 43,340 X
X Perez-Abreu & Martin-Lavielle, P.A. 11 180,000 X
X Bajo Cuva Cohen Turkel, Attorneys at Law 12 40,000 X
X Stripe Reputation 13 10,000 X
X Sandy T. Fox, P.A. 14 78,163 X
X Internal Revenue Service 15 250,000 X
X Commonwealth of Virginia 16 65,000 X
X Suntrust Credit Card 2310 18 10,200 X
X Chase Credit Card 5930 19 5,979 X
X Virginia Hospital Bill 20 975 X
Florida Family Law Rules of Procedure Form 12.902(c), Family Law Financial Affidavit (01/15)
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D. CONTINGENT ASSETS AND LIABILITIES:
INSTRUCTIONS:
If you have any POSSIBLE ASSETS (income potential, accrued vacation or sick leave, bonus, inheritance, etc.)
or POSSIBILE LIABILITIES (possible lawsuits, future unpaid taxes, debts assumed by another), you must list them here.
A B C
Contingent Assets Nonmarital
Check the line next to any contingent assets(s) which you are requesting the Possible ( x Correct Column)
judge award to you. FNN Value J. A.
A B C
Contingent Liabilities Possible Nonmarital
Check the line next to any contingent debt(s) for which youbelieve you Amount ( x Correct Column)
should be responsible. FNN Owed J. A.
0
Totals 0
Total Net Contingent Assets / Liabilities 0
Florida Family Law Rules of Procedure Form 12.902(c), Family Law Financial Affidavit (01/15) Page 12
SECTION I. PRESENT MONTHLY GROSS INCOME
Schedule of Business and/or Rental Income J.
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SECTION I. PRESENT MONTHLY GROSS INCOME
Schedule of Business and/or Rental Income J.
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FOOTNOTES
Asset and Liability Footnotes
1 Balance as of March 31, 2020.
2 Balance per statement ending March 31, 2020.
3 This account was cashed out.
4 Value as of March 31, 2020.
5 This account was cashed out.
6 This account was cashed out.
7 Value as of March 31, 2020.
8 Balance as of February 29, 2020. Father is currently unable
to pay because of insufficient cash flow.
9 Balance per statement dated April 9, 2020.
10 Balance as of April 1, 2020.
11 Balance for family case as of February 29, 2020. Father is
currently unable to pay because of insufficient cash flow.
12 Balance as of April 17, 2020. Father is currently unable to
pay because of insufficient cash flow.
13 Balance as of February 29, 2020. Father is currently unable
to pay because of insufficient cash flow.
14 Balance per pre-bill on April 21, 2020 (amount subject to
change upon finalized invoices).
15 Father is currently unable to pay because of insufficient
cash flow.
16 Balance as of February 29, 2020. Father is currently unable
to pay because of insufficient cash flow.
18 Balance per statement dated April 4, 2020.
19 Balance per statement dated March 22, 2020.
20 Balance as of February 29, 2020.
21 Balance per statement dated April 10, 2020.
22 Value estimated per Father.
23 Value of real estate per Arlington County, Virginia
Department of Real Estate Assessments dated January 1, 2019.
Balance of mortgage per statement dated March 15, 2020.
24 Value unknown.
Income and Expense Footnotes
1 Estimated annualized average.
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