___________________________________,
Pro Se
Plaintiff’s Name
___________________________________
Address
___________________________________
Zip
_______________________
Phone
IN THE DISTRICT COURT OF THE THIRD JUDICIAL DISTRICT OF
THE STATE
OF IDAHO, IN AND FOR THE COUNTY OF _________________
_______________________________________
)
) CASE NO. CV-__________________
__________________________________, )
Plaintiff, ) AFFIDAVIT
VERIFYING INCOME
-vs-
)
)
)
__________________________________, )
Defendant. )
_______________________________________)
Comes now the
plaintiff who states under oath the following
information is true:
FATHER MOTHER
1. GROSS INCOME (PER YEAR)
a. Wages, salary, commissions,
bonuses, etc. __________ __________
b. Rent,
royalties, trade, or business
income,
etc. (Net of ordinary & necessary
expenses)
__________ __________
c. Interest,
dividends, pensions, annuities,
etc.
__________ __________
d. Social
security, worker’s compensation,
unemployment,
disability, veteran’s
benefits,
etc.
__________ __________
e. Public
assistance, welfare for self
(NOT
children)
__________ __________
f. Alimony
__________ __________
g. Grants,
distributions from trusts, etc. __________
__________
h. Other
+__________ +__________
GROSS INCOME SUBTOTAL __________ __________
AFFIDAVIT VERIFYING INCOME Page 1
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