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Clear Form STATE OF NEW HAMPSHIRE SUPREME COURT Docket No. v. Plaintiff Defendant AFFIDAVIT OF ASSETS AND LIABILITIES 1. Name DOB 2. Where do you live Single 3. Marital Status Married Divorced Separated Widowed 4. List the names ages and relationships of dependents you support Full Time 5. If you are presently employed state where and for how long Part Time 6. If unemployed state last date of employment 7. When do you anticipate new employment 8. If your spouse is presently employed state where and for how long 10. List other employed household members and their weekly income 11. Please state weekly take-home amount YOURS SPOUSE S Salary/Wages Pension/Trust Benefits Unemployment Comp* Social Security Investment Income Alimony Child Support Welfare Payments Other TOTAL 12. What money is presently available to you Cash on hand Checking Account Name of Bank Savings Account Stocks/Bonds/Ira/Pension Identify 13. If inmate State amount deposited in inmate s account for the last three months Rent/Mortgage Property Taxes Heat Utilities Medical/Dental Insurance Transportation Food Clothing including gas maintenance insurance repairs specify type of expense 15. List any real estate you own its market value and the amount you owe 16. List any vehicles you own car truck motorcycle snowmobile RV their market value and the amount you owe 17. List income tax paid last year 19. Other than monthly household expenses list any bills you owe amount owed to whom and monthly payments 20. Other than those previously mentioned list anyone to whom you owe money amount and when it is due 21. List court-ordered bills i*e* alimony judgment in law suit etc* 22. If anyone owes you money state name address amount due and when due 23. List any property you have transferred within the last three years to whom and for what price 24. List any other assets or expenses not previously mentioned IF YOU NEED ADDITIONAL SPACE TO ANSWER ANY QUESTION ABOVE ATTACH A SHEETOF PAPER TO THIS FORM AND PROVIDE THE ADDITIONAL INFORMATION ON IT. I swear the foregoing information and any information provided by me on any attached sheets is true and correct to the best of my knowledge under penalties of law. Date Signature The following section must be completed only by inmates. I swear under oath that this civil claim has not been previously brought against the same parties or from the same operative facts in any state or federal court. I further swear that the foregoing information and any information provided by me on any attached sheets is true and correct to the best of my knowledge under penalties of law. Name DOB 2. Where do you live Single 3. Marital Status Married Divorced Separated Widowed 4. List the names ages and relationships of dependents you support Full Time 5. If you are presently employed state where and for how long Part Time 6. If unemployed state last date of employment 7. If you are presently employed state where and for how long Part Time 6. If unemployed state last date of employment 7. When do you anticipate new employment 8. If your spouse is presently employed state where and for how long 10..

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