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Use this template/form as a Family Law Financial Affidavit Long Form in the State of Florida


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Text version of this Form

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INSTRUCTIONS FOR FLORIDA FAMILY LAW RULE OF PROCEDURE FORM

12.902(c), FAMILY LAW FINANCIAL AFFIDAVIT (LONG FORM)(09/12)

When should this form be used?

This form should be used when you are involved in a family law case w hich requires a financial affidavit

and your individual gross income is $50,000 OR MORE per year unless:

(1) You are filing a simplified dissolution of marriage under rule 12.105 and both parties have

waived the filing of financial affidavits;

(2) you have no minor children, no support issues, and have filed a written settlement agreement

disposing of all financial issues; or

(3) the court lacks jurisdiction to determine any financial issues.

This form should be typed or printed in black ink. After completing this form, you should sign the form

before a notary public or deputy clerk. You should then file the original with the clerk of the circuit

court in the county where the petition was filed and keep a copy for your records.

What should I do next?

A copy of this form must be served on the other party in your case within 45 days of being served with

the petition, if it is not served on him or her with your initial papers. Service must be in accordance

with Florida Rule of Judicial Administration 2.516.

Where can I look for more information?

Before proceeding, you should read “General Information for Self-Represented Litigants” found at the

beginning of these forms. The words that are in “bold underline” in these instructions are defined

there. For further information, see Florida Family Law Rule of Procedure 12.285.

Special notes…

If you want to keep your address confidential because you are the victim of sexual battery, aggravated

child abuse, aggravated stalking, harassment, aggravated battery, or domestic violence do not enter the

address, telephone, and fax information at the bottom of this form. Instead, file Request for

Confidential Filing of Address, Florida Supreme Court Approved Family Law Form 12.980(h).

The affidavit must be completed using monthly income and expense amounts. If you are paid or your

bills are due on a schedule which is not monthly, you must convert those amounts. Hints are provided

below for making these conversions.

Instructions for Florida Family Law Rules of Procedure Form 12.902(c), Family Law Financial Affidavit (Long Form)

(09/ 12)

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

Hourly amount x Hours worked per week = Weekly amount

Weekly amount x 52 Weeks per year = Yearly amount

Yearly amount ÷ 12 Months per year = Monthly Amount

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

Daily amount x Days worked per week = Weekly amount

Weekly amount x 52 Weeks per year = Yearly amount

Yearly amount ÷ 12 Months per year = Monthly Amount

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

Weekly amount x 52 Weeks per year = Yearly amount

Yearly amount ÷ 12 Months per year = Monthly Amount

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

follows:

Bi-weekly amount x 26 = Yearly amount

Yearly amount ÷ 12 Months per year = Monthly Amount

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

follows:

Semi-monthly amount x 2 = Monthly Amount

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 for Florida Family Law Rules of Procedure Form 12.902(c), Family Law Financial Affidavit (Long Form)

(09/ 12)

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IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,

IN AND FOR COUNTY, FLORIDA

Case No.:

Division:

,

Petitioner,

and

,

Respondent.

FAMILY LAW FINANCIAL AFFIDAVIT (LONG FORM)

($50,000 or more Individual Gross Annual Income)

I, {full legal name} , being sworn, certify

that the following information is true:

SECTION I. INCOME

1. My age is: ___________________

2. My occupation is: ________________________________________________________________

3. I am currently

[Check 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: __________________________________________________________

____________________________________________________________________________

b. ____ Employed by: ____________________________________________________________

Address: ____________________________________________________________________

City, State, Zip code: ________________________________ Telephone Number: _________

Pay rate: $ ______ ( ) every week ( ) every other week ( ) twice a month

( ) monthly ( ) other: ________________________________________________________

If you are expecting to become unemployed or change jobs soon, describe the change you

expect and why and how it will affect your income: _________________________________

___________________________________________________________________________

____ 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.

Florida Family Law Rules of Procedure Form 12.902(c), Family Law Financial Affidavit (Long Form) (09/12)

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c. _____ Retired. Date of retirement: _______________________________________________

Employer from whom retired: ___________________________________________________

Address: _____________________________________________________________________

City, State, Zip code: _______________________________ Telephone Number: __________

LAST YEAR’S GROSS INCOME: Your Income Other Party’s Income (if known)

YEAR_____ $ _______ $ _______

PRESENT MONTHLY GROSS INCOME:

All amounts must be MONTHLY. See the instructions with this form to figure out money amounts for

anything that is NOT paid monthly. Attach more paper, if needed. Items included under “other” should

be listed separately with separate dollar amounts.

1. $______ Monthly gross salary or wages

2. _______ Monthly bonuses, commissions, allowances, overtime, tips, and similar payments

3. _______ Monthly business income from sources such as self-employment, partnerships, close

corporations, and/or independent contracts (Gross receipts minus ordinary and necessary

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

4. _______ Monthly disability benefits/SSI

5. _______ Monthly Workers’ Compensation

6. _______ Monthly Unemployment Compensation

7. _______ Monthly pension, retirement, or annuity payments

8. _______ Monthly Social Security benefits

9. _______ Monthly alimony actually received (Add 9a and 9b)

9a. From this case: $________

9b. From other case(s): ________

10. _______ Monthly interest and dividends

11. _______ Monthly rental income (gross receipts minus ordinary and necessary expenses 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 (Attach sheet itemizing each item and amount.)

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

Any other income of a recurring nature (identify source)

15. _______________________________________________________________________________

16. _______________________________________________________________________________

17. $_________ TOTAL PRESENT MONTHLY GROSS INCOME (Add lines 1 through 16).

PRESENT MONTHLY DEDUCTIONS:

All amounts must be MONTHLY. See the instructions with this form to figure out money amounts for

anything that is NOT paid monthly.

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

Florida Family Law Rules of Procedure Form 12.902(c), Family Law Financial Affidavit (Long Form) (09/12)

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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).

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:

1. $______ Monthly mortgage or rent payments

2. _______ Monthly property taxes (if not included in mortgage)

3. _______ Monthly insurance on residence (if not included in mortgage)

4. _______ Monthly condominium maintenance fees and homeowner’s association fees

5. _______ Monthly electricity

6. _______ Monthly water, garbage, and sewer

7. _______ Monthly telephone

8. _______ Monthly fuel oil or natural gas

9. _______ Monthly repairs and maintenance

10. _______ Monthly lawn care

11. _______ Monthly pool maintenance

12. _______ Monthly pest control

13. _______ Monthly misc. household

14. _______ Monthly food and home supplies

15. _______ Monthly meals outside home

16. _______ Monthly cable t.v.

17. _______ Monthly alarm service contract

18. _______ Monthly service contracts on appliances

19. _______ Monthly maid service

Other:

20. __________________________________________________________________________________

21. __________________________________________________________________________________

22. __________________________________________________________________________________

23. __________________________________________________________________________________

24. __________________________________________________________________________________

25. $_______ SUBTOTAL (add lines 1 through 24).

Florida Family Law Rules of Procedure Form 12.902(c), Family Law Financial Affidavit (Long Form) (09/12)

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AUTOMOBILE:

26. $______ Monthly gasoline and oil

27. _______ Monthly repairs

28. _______ Monthly auto tags and emission testing

29. _______ Monthly insurance

30. _______ Monthly payments (lease or financing)

31. _______ Monthly rental/replacements

32. _______ Monthly alternative transportation (bus, rail, car pool, etc.)

33. _______ Monthly tolls and parking

34. _______ Other: _________________________________________________

35. $_______ SUBTOTAL (add lines 26 through 34)

MONTHLY EXPENSES FOR CHILDREN COMMON TO BOTH PARTIES:

36. $______ Monthly nursery, babysitting, or day care

37. _______ Monthly school tuition

38. _______ Monthly school supplies, books, and fees

39. _______ Monthly after school activities

40. _______ Monthly lunch money

41. _______ Monthly private lessons or tutoring

42. _______ Monthly allowances

43. _______ Monthly clothing and uniforms

44. _______ Monthly entertainment (movies, parties, etc.)

45. _______ Monthly health insurance

46. _______ Monthly medical, dental, prescriptions (nonreimbursed only)

47. _______ Monthly psychiatric/psychological/counselor

48. _______ Monthly orthodontic

49. _______ Monthly vitamins

50. _______ Monthly beauty parlor/barber shop

51. _______ Monthly nonprescription medication

52. _______ Monthly cosmetics, toiletries, and sundries

53. _______ Monthly gifts from child(ren) to others (other children, relatives, teachers, etc.)

54. _______ Monthly camp or summer activities

55. _______ Monthly clubs (Boy/Girl Scouts, etc.)

56. _______ Monthly time-sharing expenses

57. _______ Monthly miscellaneous

58. $_______ SUBTOTAL (add lines 36 through 57)

MONTHLY EXPENSES FOR CHILD(REN) FROM ANOTHER RELATIONSHIP

(other than court-ordered child support)

59. $________________________________________________________________________________

60. __________________________________________________________________________________

61. __________________________________________________________________________________

62. __________________________________________________________________________________

63. $_______ SUBTOTAL (add lines 59 through 62)

Florida Family Law Rules of Procedure Form 12.902(c), Family Law Financial Affidavit (Long Form) (09/12)

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MONTHLY INSURANCE:

64. $______ Health insurance, excluding portion paid for any minor child(ren) of this relationship

65. _______ Life insurance

66. _______ Dental insurance

Other:

67. __________________________________________________________________________________

68. __________________________________________________________________________________

69. $_______ SUBTOTAL (add lines 64 through 68)

OTHER MONTHLY EXPENSES NOT LISTED ABOVE:

70. $______ Monthly dry cleaning and laundry

71. _______ Monthly clothing

72. _______ Monthly medical, dental, and prescription (unreimbursed only)

73. _______ Monthly psychiatric, psychological, or counselor (unreimbursed only)

74. _______ Monthly non-prescription medications, cosmetics, toiletries, and sundries

75. _______ Monthly grooming

76. _______ Monthly gifts

77. _______ Monthly pet expenses

78. _______ Monthly club dues and membership

79. _______ Monthly sports and hobbies

80. _______ Monthly entertainment

81. _______ Monthly periodicals/books/tapes/CDs

82. _______ Monthly vacations

83. _______ Monthly religious organizations

84. _______ Monthly bank charges/credit card fees

85. _______ Monthly education expenses

86. ______ Other: (include any usual and customary expenses not otherwise mentioned in the items

listed above)______________________________________________________________

87. __________________________________________________________________________________

88. __________________________________________________________________________________

89. __________________________________________________________________________________

90. $_______ SUBTOTAL (add lines 70 through 89)

MONTHLY PAYMENTS TO CREDITORS: (only when payments are currently made by you on outstanding

balances). List only last 4 digits of account numbers.

MONTHLY PAYMENT AND NAME OF CREDITOR(s):

91. $_________________________________________________________________________________

92. __________________________________________________________________________________

93. __________________________________________________________________________________

94. __________________________________________________________________________________

95. __________________________________________________________________________________

96. __________________________________________________________________________________

97. __________________________________________________________________________________

98. __________________________________________________________________________________

99. __________________________________________________________________________________

100. ______________________________________________________________________________

101. ______________________________________________________________________________

102. ______________________________________________________________________________

Florida Family Law Rules of Procedure Form 12.902(c), Family Law Financial Affidavit (Long Form) (09/12)

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103. ______________________________________________________________________________

104. $_______ SUBTOTAL (add lines 91 through 103)

105. $_______TOTAL MONTHLY EXPENSES:

(add lines 25, 35, 58, 63, 69, 90, and 104 of Section II, Expenses)

SUMMARY

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

107. $_______ TOTAL MONTHLY EXPENSES (from line 105 above)

108. $_______ SURPLUS (If line 106 is more than line 107, subtract line 107 from line 106. This is the

amount of your surplus. Enter that amount here.)

109. ($______)(DEFICIT) (If line 107 is more than line 106, subtract line 106 from line 107. This is

the amount of your deficit. Enter that amount here.)

SECTION III. ASSETS AND LIABILITIES

A. ASSETS (This is where you list what you OWN.)

INSTRUCTIONS:

STEP 1: In column A, list a description of each separate item owned by you (and/or your spouse, if

this is a petition for dissolution of marriage). Blank spaces are provided if you need to list more than

one of an item.

STEP 2: If this is a petition for dissolution of marriage, check the line in Column A next to any item

that you are requesting the judge award to you.

STEP 3: In column B, write what you believe to be the current fair market value of all items listed.

STEP 4: Use column C 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 belongs. (Typically, you will only use Column C if property

was owned 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 B C

ASSETS: DESCRIPTION OF ITEM(S) Current Nonmarital

Fair (Check correct

LIST ONLY LAST FOUR DIGITS OF ACCOUNT NUMBERS. Market

Check the line next to any asset(s) which you are requesting the judge award Value column)

to you. husband wife

Cash (on hand) $

Cash (in banks or credit unions)

Stocks/Bonds

Florida Family Law Rules of Procedure Form 12.902(c), Family Law Financial Affidavit (Long Form) (09/12)

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Notes (money owed to you in writing)

Money owed to you (not evidenced by a note)

Real estate: (Home)

(Other)

Business interests

Automobiles

Boats

Other vehicles

Retirement plans (Profit Sharing, Pension, IRA, 401(k)s, etc.)

Furniture & furnishings in home

Furniture & furnishings elsewhere

Collectibles

Florida Family Law Rules of Procedure Form 12.902(c), Family Law Financial Affidavit (Long Form) (09/12)

———————– Page 10———————–

Jewelry

Life insurance (cash surrender value)

Sporting and entertainment (T.V., stereo, etc.) equipment

Other assets:

Total Assets (add column B) $

B. LIABILITIES/DEBTS (This is where you list what you OWE.)

INSTRUCTIONS:

STEP 1: In column A, list a description of each separate debt owed by you (and/or your spouse, if

this is a petition for dissolution of marriage). Blank spaces are provided if you need to list more than

one of an item.

STEP 2: If this is a petition for dissolution of marriage, check the line in Column A next to any debt(s)

for which you believe you should be responsible.

STEP 3: In column B, write what you believe to be the current amount owed for all items listed.

STEP 4: Use column C only if this is a petition for dissolution of marriage and you believe an item

is “nonmarital,” meaning the debt belongs to only one of you and should not be divided. You

should indicate to whom you believe the debt belongs. (Typically, you will only use Column C if the

debt was 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.)

Florida Family Law Rules of Procedure Form 12.902(c), Family Law Financial Affidavit (Long Form) (09/12)

———————– Page 11———————–

A B C

LIABILITIES: DESCRIPTION OF ITEM(S) Current Nonmarital

Amount (Check correct

LIST ONLY LAST FOUR DIGITS OF ACCOUNT NUMBERS. Owed

Check the line next to any debt(s) for which you believe you should be column)

responsible.

husband wife

Mortgages on real estate: First mortgage on home $

Second mortgage on home

Other mortgages

Charge/credit card accounts

Auto loan

Auto loan

Bank/Credit Union loans

Money you owe (not evidenced by a note)

Judgments

Other:

Total Debts (add column B) $

Florida Family Law Rules of Procedure Form 12.902(c), Family Law Financial Affidavit (Long Form) (09/12)

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C. NET WORTH (excluding contingent assets and liabilities)

$_______Total Assets (enter total of Column B in Asset Table; Section A)

$_______Total Liabilities (enter total of Column B in Liabilities Table; Section B)

$_______TOTAL NET WORTH (Total Assets minus Total Liabilities)

(excluding contingent assets and liabilities)

D. 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.

A B C

Contingent Assets Nonmarital

Possible (Check correct

Check the line next to any contingent asset(s) which you are requesting the Value column)

judge award to you. wife

husband

$

Total Contingent Assets $

A B C

Contingent Liabilities Nonmarital

Possible (Check correct

Amount column)

Check the line next to any contingent debt(s) for which you believe you Owed

should be responsible.

husband wife

$

Total Contingent Liabilities $

E. 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.

Florida Family Law Rules of Procedure Form 12.902(c), Family Law Financial Affidavit (Long Form) (09/12)

———————– Page 13———————–

[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 financial affidavit 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

Sworn to or affirmed and signed before me on by .

NOTARY PUBLIC or DEPUTY CLERK

[Print, type, or stamp commissioned name of

notary or deputy clerk]

__ Personally known

__ Produced identification

Type of identification produced

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

[fill in all blanks] This form was prepared for the: {choose only one} ( ) Petitioner ( ) Respondent

This form was completed with the assistance of:

{name of individual} ___________________________________________________________,

{name of business} _______________________________________________________________,

{address} ___________________________,

{city} ____,{state} _, {telephone number} ______________________ .

Florida Family Law Rules of Procedure Form 12.902(c), Family Law Financial Affidavit (Long Form) (09/12)

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