IN TllE CIRCUIT COURT OF TllE FIFTEENTH JUDICl,\L CIRCLJIT.

IN ,.\,\JI) FOR Pi\l..\I !1E,\l 'I I COUNTY. FLORID1\

<:1si:~

(!j/g;6tJr!lfl 11Pt<R;(;Orz) P@ft

I \1111011i:r,
.111LI

2011 []~ oi 2112 x~~x 1~1e

l)j \'IS !Oil: - - - - - - - - - - - - - - - - -

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Respondent.

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F..\l\llLY L\ W FINANCIAL AFFIDA YIT tSHORT FOH;\ll

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Under .'i.50.(HJ(l Individual ()ro,s ,\nnual lm:nmel

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i>ay rate: S
l I every week ( I every 111her week ( I twi..:e a month ( ) monthly p~J:tU~ --::--=
.::Check here if unemployed and cxplain on a separate sheet your efforts to find employment. 11//lt{fZJ~ ~J~
SECTION I. PRESENT i\IONTHLY CROSS INC01\IE:

\II amounts must he .\IONTHL Y. See the ins1ru..:11011s w11h 1h1~ form 111 ligure 0111 money amounts for anythln\! that is .~OT
puid mon1hly. ,.\llm:h more paper. ti nccdctJ. ltt:ms int:ludctJ under .. 111hcr should he listed scpar:uely with separate dollar
.lllllllllllS .

.\ lonthly gross salary 1>r wage~

.\lnnthly bonuses . ..:ommis~ions. allowun..:es. overtime. rips. und similar payments
3. :\lnnthly husiness im:omc fmm \ources ~u..:h as ~df-employment. partnerships.
~Ii 1se ..:orporut 111ns. ~nd/or independent conlra..:ts t gross receiprs minus ordinary
and neces.-.ury exr>enses required to prodUL:e incomel tc At1ach sheet iremizing
,uch im:ome and expenses. 1
\lonrhly di~ability benefits/SS I
-I.
5. .\lon!hly Workers Compensation
(1.
;\lonthly Unemployment Compensation
7. \fonrhly pension. retiremenr. or annuity payments
s. Monthly So..:iul Se..:uriry benetils
'J.
.\lonthly alimony a..:tually re..:eived
Ya. From this case:
lJb. From other case( s l:
Add 9a and 9b
10. \lonthly interest and dividends
11. \lomhly rental income I gross receipts minus ordinary and necessary expenses
rc4u1red to prm.lu..:e im:ome l to ,.\tta..:h .<iheet Itemizing su..:h income und
C'.\penst!
items.I
I~ . .\lonthly income from royallies. trusts. or esrnres
I.>. \lonthly reimbursed expenses and in-kind paymenrs to the e.xten! tha! !hey
r~t.luce personal living expenses
1-L \lonrhly ~;_iins tlerived from dealing in properiy 1no1 including nunre..:urrin!,!
':_!:tins 1
15 ..-\ny 111her income of a relurring nuture 1li~1 source l - - - - - - - - - -

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17. PRESENT :\IONTHLY GROSS INCOME (Add lines 1-161

TOTAL:

U1ndfl fi1m1/I' /1111 f/11/<'J 111 Prllf't'1/11rt' fnl'm 12.'AJ!l/>J. /111111/1 11111 fi1111ntw/ .-\l/itf11l'it 1.\/1or1 f11r11111111111ti1

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l'tffSENT :\IONTHL\' l>El>lll'TIONS:

1:i. \l11111hlv ll'dl'ral. ,1.111.. and h11.:.11 1111.:111111:: ra.x 11.11rrl'l.'.l<'1I lnr 1ilinc \l:llll\ :11111
1thn11ahlc ill'fll'fllltnl.\ .111cl rnn11m.: .~ l1ah1!\IJ.Si'' L: ()JJ/l#.'f"r-)
,, i:ili11c S1a111~
- -/Ll/fj(r J0'fl'lrJ/V/ Uli .'i11111bl'r 111 d1.pcntli:n1.~ da1ml'il _ /
__
I'I :'\lomhlv FIL'.\ or \l'lf-<'mplovml'lll 1:1.XL'\
~ti. \l1111thlv ,\lcLlit::m: p;i:v1m111.~
: I. \lonlhlv ma11da111rv 11ni1111 dues
'' :-0.lonrhly manJa1or:v rcrircrncnl payment~
~.\. \lnnthly hL'ullh 111.\lll'Jnt:t! pa)mcnts r im:ludim.! llt!nlul insurance I. c.,duding
p11r1111n paid Im anv minor chihlr<'n 111 rhis relationship
~ L l\lonthly c1111r1-11rdcrcd .:hild ~upport :11.:tually paid lnr chilciren Imm another

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r.:b1111n~hip

.\Lid ~Sa and ~5b

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~6. Tl'LO(T),R\lLUPEs:DTU\~fTUTIOENSSA~~.Ll~w,l\,8LhE UNh~~R SECTION 61.JO.

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PRESENT NET :\IONTHLY INCOME <Suo1rac1line26 from line 17)

SECTION II. ,\ VER1\GE MONTHLY EXPENSES
.\. HOUSEHOLD:
~tort gage or rent
'\ ....,,.~........--....r--I 'roperty

wxe~

ll. AUTOMOBILE

c.

)-;;:j.._,.,_~~-~-:

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)

_______
.........-......---

~-......

) --=----=-.......,--=-

) ,9 '801 32

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25.

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--~i..-~~T-j2.......,-f=-..,....

0' O#

E. OTHER EXPENSES NOT LISTED ,\~VE

Clorliinl,.!
.,~, ,ofJJJ~S
~
.\kdical/Denral 1irttlfMutecF\'
) /tJO
<irooming t5!1 PPLl{i:5
' .
En1er1:iinment
-;
1;ir1s
\ _...;;'"":;..._'v,,,_,,_..-H.eligious 11rganiza1 ions
" _...,.>_..52......
?i~\ liscell:ineous
<l1her:

--------

-.....

l-:f(J

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______

~-----)

_______
_____
___ __

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...
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CHILDIREN>"S EXPENSES
)
Day care
')
LunL'h money
s
Clo1hing
'5
Grooming
')
c iifls for holidays
.\ lcdical/Denral <unini;ured I
)
I )1hcr:

-11

!7. $

ia.,oline
Repairs
Insurance

' -~~,............--

is

lJlilitil'S
r.:lcphr>ne
F1111d
\ kal.~ our.~iue home
~1ainte'Jjl!1cc/Repa irs
( Jtht!'r: f.!)Jfl'1?;) Pf1;~

\lonrhly i.:1111rr-11rJcrcd alimony ac111ally ptrnlO

~5:i. rrnm thts .:a.\c:
) ~
::'ih. from urher i.:asc1s1:
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______
_,_.

F. PAYMENTS TO CREDITORS

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) -...!..<:.W..'"'"----"
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______

~--1-t,.:.....,_

0. INSURANCE
;,,
\ lt!dical/DL'nral
L'hildrrenl'~ rnedic:illdenral s
....
Lit'c
)
1 Jrher:

"------

______
"-----a?J9ci 1f
"'-----...

2:i. TOTAL ~IONTHL Y EXPENSES <add ALL mnnrhly ;.irnounrs in

. \ 1hm11!,!h F :.ihnv~ 1
. 1,,,, 1/11/ 1111111\'I11w Hnlrr 111 i"r111r,/111r f111m I !. 1J11!1l11. 1'111111/v 1'1111 /a"i11ur111111 lllid11, 11 t \f,,111

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--1<::,.i..>.L.Clc<..,._..

J.,,,,,,, ,111/1/lh1

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TOT,\L l'ltESF.NT :\IONTHl.Y NET INCOME

lr1>m lim: 27 I SECTlllN I. INCO~IF.l

.\0. TOT.\L .\IONTHL V E:XPENSE'.S 1 from line!~ ahovl' I

.11. SURl'LUS <If line: ~9 i~ mnre than lint: .Ill. ,11h1rac1 lin~ _,II frnm line: !'J.
!'hi~ is 1hc: am1111nt 111 your ~urplu:.. Enter 1hut :.imnunt ht!rl!. I

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1l>EFtCITl l If line .10 b more than line 21J. ~11h1rac1 lint: 29 frnm line .Ill.

l'his is 1he :.irnount

01

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y1111r dctii:ir. Entt:r that amount here.)

.___ _
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SECTION Ill. ,\SSETS ANO U,\61UTIES

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\.'SI! the nunmarital rnlumn univ it' this is a pl'tilion ror rlissolution of marria!ll.' and you ht-lit-ve an itl'm is ""nonmarital."
ml'anin~ ii h11lonl!S to only onl.' 01 you and should nnl hi! 11ivid~. Ycu ~hmrlu indicate 111 whom yuu hl.'llew 1hc ncmt sl or
.l..:hl hcltml!s. t fy!'il.'ally. ~11u will 1111ly 11~ this column 11 pmpmy/ul!ht was ownclllow~ hy one ~pou:;.: hcfnre 1he m.irna!!e.
Sec the "t;eneral lnl'ormution t"<1r Sl!URepresenled Litic11nts" fount! at the hcl,!tnnin!,! nt' the~ t'nrms ;ind ~cction h 1.1175< I 1.
Flurilla S1:i1111cs. for 1.ktini1ions ol "'marital" ;ind "nnnmarual'" ;isscts <rnll li<rhihries.1

.\. ,\SSETS:

DESCRIP1"10N Of ITEMISl. Lisl a description of each separate item owrn:d hy

you 1and/or your spoUSlt', if thill is a petition ror dissolution of marrial(el.

00 NOT LIST ACCOUNT NUMBERS. I/ the holC next lo any as.wtlsl which you
) ure ttqu~tinR the judge award to rnu.
1 ::

C;ish fnn hand I

.::i Ca~h

(in bank.~

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Currmt 1-'alr

:\h1rket Value

1:rcdit unions1

:::: Stt11:ks. Bonds. :--!11tt:s

:.. Real estate: t Home I

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ht:re ii audi1i11nal :Jl!eS are :Jll:ll.'.hed.

Total Assets Iadd next column)

/ )Ill"'" /111111/\'

I .1m Hult'\,,,

,, /1 \t1lw,- >'1111..,1 a

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P1'(1f't1/111t' ,.,,,,,,

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r'111111/\' I 1111" rllllllfl'lill. "';,'"''"I '''""' /-lll'nll ,,,..,,,,,,)

.'lonmarital
'' rnfTfCt column I
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..
I\. U..\BIUTIES:
I

iDESCRIPTION
o~
~
~pot1M!.

l.i~t 1t~rip1ion

ITF.:\llSI.
a
of t':.n:h <Wp11r:ate tlt'hl owed hv
i 1111 tand/nr yuur
if Ihis ill a t~tilion for 11issoluliun 111" marri:.11.:el. UO '.'JOT
! UST ,\CCOllNT '.'IU'.\lBERS. v lhl! hox ni!lll Jn any dehtW for which vou hl'lievt'
I1'IU ~hould he rl'll""lllSihle.
.
.
,

\, \lnrt!!:J!!es

011

rc:.il

C'~talC': Fir~

"mm:.rilul
( 'urri:nt
.\mount

u ... n1

1'

rnrrfi'I l'ulumn I

1111\l>:mt.I

wi ft!

mort!!;Jl.!e on home

: Sccontl mon!!al!C' on ht1me

)1hcr mllrt!!a!!cs

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.\1110 loam

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.: Charne/crc-di1 c:.ird accounts

I.: Other
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.- / he-re if audi1i11nal al!C'S are a11achcJ.

Total Debts

tat.Id ne111 column I

C. CONTINGENT ASSETS AND LIABILITIES:

is

I :-.ISTRuCTIONS: ti' you have :.my POSSIBLE assel!I f i11Lnme pmential. :.u:crucll 11aca1i11n or srtk lt!'ave. h11nus. 111hert1;mce. c1c. I
.1r POSSIBLE liuhilities I possihle luw.~ui1s. l111urc unraill 1;:u1cs. rnntmgen1 tait liubilities. Jchts assumed hy ann1lwr1. ynu must
li'I 1hem here

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Conlin21nt A.'i.Wtli
l'omhle Volue

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I 1he ho nut to any contln11m111."il'letfSI whidl you an HilUtstlnq the jud11e award to you.
,...

coma column I

hushand

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Tot.al Contin_g_ent Assel.!I

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Con tin llftll Llabillllesi

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the holl' nut to any conllnl!l!nt ddlttu for wbidl JIOQ hellewe you .hoold he

~pon.,ihle.

'.'fnnm1oritnl
roo.~ihlr

Ow~

hmhanc.l

--

Total Conti'!ltena Liabilities

'!i

.' !,,,,,,,, F111111/\o /jlh' H1dr1 ,,1JJfflf"t"tillr,.1-ilfm I !. 1J11!//n l-"1111111\ l.Jtlf f mon,.,11/. \lfid10-111\hon1-,,,.,,,, 11JJlfllu
'' 11 \11Y11'1' l'llfl'~I II .J p,,~,

t ~ cnrrect column I

Amount

J!

.
'>ECTION IV. ( 111u> SIJPrOJn (;IJlllEl.INES WOt<KSllEt-:T
, 1-!Druh.1 bmilv La\~ l<11l1:s ''' f'ro~ctlure hirrn 12. 1J11211.1. Child S11rrnr1 < i1111klinl'' W11rk,hl.'l'I. ,\lti~T he l1lld \qlh
:ilc l1111r1 a1 11r pnnr 111 a h~artm.! 111 e,1:ihll~h nr 11111dity dHtd '"rror1. I h" n~q111rL'lllt!'nt lan11111 lc '.\atHd hy 1lw

1arr1n.1
i" 11ne 1111ly I
. \ Child Support ( ;uidelines Worksheet IS or WI LL Rf.: filed in this 1:ase. l"hi, l:il~c 111v11hi:-, 1he
'-''1:.ihli~hmem or mmli Iic:.u ion of i:hild ~upp11r1.
\Child Supp<>rt (9uidelines Worksheet IS NOT heine tiled in thio; case. fhe e~1:.ihli,hmen111r
11wdifka1i11n oi 1.'hild support is n111 an issue in rhis .:a.,e.

I l.'crtily 1hat a 1.'llPY of this Jm:ument wa~ \ ..J one only\

hand
1 111a1leJ 1 1 1:.1.'\cd :.inll mailed I
.tclivcrcd 1111hc pcrson1s1 lt~ted hclow on /dwe/ - - - - - - - - - - - - - - - - - - - - - - - - - -

.'lame: - - - - - - - - - - - - - - - - - - - - - .\duress:--------------------~

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<:i1y. Slale. Z i p : - - - - - - - - - - - - - - - - - r::.ix Numht:r: - - - - - - - - - - - - - - - - - - -

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( )ther party or his/her attorney:

I understand that l am swearin~ or al'linnin~ under oath to the truthrulness of the claims mode in
this affidavit and that the punishment for knowin~. ma inR
false ~la
includes ti
nd/or
i rnprisonmenl. .

'""" ;oJdzj?01t
STA TE OF FLORIDA
COUNTY OF PALM BEACH

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Sworn tn nr :.iftirmed and signed belore me on_./_o_,f_.Q......,1-f/_,/'+/'___ by

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.'iOT ARY PUBLIC or DEPUTY CLERK

!Prim. 1ype.

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}(_rcrson:.illy known
__ Prndm:ed identitic:uion
r~p~ of id~nlifo:ation prmJuced:
If:\ NONLAWYER HELPED YOU FILL OUT THIS FORM. HE/SHE MUST FILL IN THE BLANKS
BELOW: I till in all blanhl
I. / l11ll le11til 1111111t' and trade m1111e 11/ 11m1lm1ya/ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
11onlawyer. 1111.::.itcd at f.Hree1/ - - - - - - - - - - - - - - - - - - - lity/ - - - - - - - - - - J
/ plio11f! J
, helped / 11ct111e/ - - - - - - - - - - - - - - - - - - - - - - - .,ho i' 1he I v one 1rnly I_ pl'litioner or _ r~spondenr. fill out this form.
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;:h,rii/11 J- 111111/r I 1111 H11/~1 "' Pro11durr ,.,,,.,,, I!. 1111]1b1. finml\ 1

,u, l-'i111mr1nl. \l1i,/11111 '''",,.'

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