Financial affidavit

Sample data

Form 12.902(c) layout · monthly amounts

Show all lines

Next best action

Replace 'Client est.' sources with documents

Affidavit builder (v3.3)

Runs on this computer

Working net figures

Client net monthly income

Source: 2025 W-2 and YTD pay stub — demo

Other party net monthly income

Source: 2025 W-2 and last 3 pay stubs — demo

Children’s insurance per month

Source: Sample premium records / v3.3 fixture, 2026-10-29

Child care per month

Source: After-school program and summer camp, averaged — Elena pays the provider (FA line 40). Demo.

Don't type confidential facts.

Original reported affidavit — not working figures

Line	Description	Petitioner	Respondent (client)	Source
Income
1	Gross salary or wages	$5,400.00	$8,000.00	Original supplied v3.3 case-file / party affidavit, 2026-10-29
	Total income	$5,400.00	$8,000.00
Deductions
18	Federal, state, and local income tax	$10.33	$1,024.17	Original supplied v3.3 case-file / party affidavit, 2026-10-29
19	FICA or self-employment taxes	$334.80	$496.00	Original supplied v3.3 case-file / party affidavit, 2026-10-29
20	Medicare payments	$78.30	$116.00	Original supplied v3.3 case-file / party affidavit, 2026-10-29
23	Health insurance for you only	$270.00	$240.00	Original supplied v3.3 case-file / party affidavit, 2026-10-29
	Total deductions	$693.43	$1,876.17
Expenses
1	Reported expense — line 1	$2,140.00	$1,850.00	Original supplied v3.3 case-file / party affidavit, 2026-10-29
5	Reported expense — line 5	$210.00	$160.00	Original supplied v3.3 case-file / party affidavit, 2026-10-29
6	Reported expense — line 6	$70.00	$55.00	Original supplied v3.3 case-file / party affidavit, 2026-10-29
7	Reported expense — line 7	$110.00	$120.00	Original supplied v3.3 case-file / party affidavit, 2026-10-29
14	Reported expense — line 14	$900.00	$650.00	Original supplied v3.3 case-file / party affidavit, 2026-10-29
15	Reported expense — line 15	$150.00	$220.00	Original supplied v3.3 case-file / party affidavit, 2026-10-29
16	Reported expense — line 16	$95.00	$90.00	Original supplied v3.3 case-file / party affidavit, 2026-10-29
28	Reported expense — line 28	$220.00	$260.00	Original supplied v3.3 case-file / party affidavit, 2026-10-29
32	Reported expense — line 32	$160.00	$185.00	Original supplied v3.3 case-file / party affidavit, 2026-10-29
33	Reported expense — line 33	$612.00	$0.00	Original supplied v3.3 case-file / party affidavit, 2026-10-29
40	Reported expense — line 40	$640.00	$0.00	Original supplied v3.3 case-file / party affidavit, 2026-10-29
43	Reported expense — line 43	$150.00	$120.00	Original supplied v3.3 case-file / party affidavit, 2026-10-29
48	Reported expense — line 48	$120.00	$80.00	Original supplied v3.3 case-file / party affidavit, 2026-10-29
50	Reported expense — line 50	$290.00	$0.00	Original supplied v3.3 case-file / party affidavit, 2026-10-29
81	Reported expense — line 81	$90.00	$75.00	Original supplied v3.3 case-file / party affidavit, 2026-10-29
84	Reported expense — line 84	$60.00	$40.00	Original supplied v3.3 case-file / party affidavit, 2026-10-29
17	Reported expense — line 17	$0.00	$35.00	Original supplied v3.3 case-file / party affidavit, 2026-10-29
30	Reported expense — line 30	$0.00	$60.00	Original supplied v3.3 case-file / party affidavit, 2026-10-29
31	Reported expense — line 31	$0.00	$15.00	Original supplied v3.3 case-file / party affidavit, 2026-10-29
49	Reported expense — line 49	$0.00	$75.00	Original supplied v3.3 case-file / party affidavit, 2026-10-29
60	Reported expense — line 60	$0.00	$90.00	Original supplied v3.3 case-file / party affidavit, 2026-10-29
72	Reported expense — line 72	$0.00	$45.00	Original supplied v3.3 case-file / party affidavit, 2026-10-29
85	Reported expense — line 85	$0.00	$35.00	Original supplied v3.3 case-file / party affidavit, 2026-10-29
86	Reported expense — line 86	$0.00	$60.00	Original supplied v3.3 case-file / party affidavit, 2026-10-29
87	Reported expense — line 87	$0.00	$45.00	Original supplied v3.3 case-file / party affidavit, 2026-10-29
90	Reported expense — line 90	$0.00	$80.00	Original supplied v3.3 case-file / party affidavit, 2026-10-29
95	Reported expense — line 95	$0.00	$500.00	Original supplied v3.3 case-file / party affidavit, 2026-10-29
	Total expenses	$6,017.00	$4,945.00

Don't type confidential facts.