IN THE CIRCUIT COURT OF THE _____ JUDICIAL CIRCUIT,
IN AND FOR _____ COUNTY, FLORIDA

Case No.: ____________
Division: ____________

________________________,
Petitioner/Counter-Respondent,

and

________________________,
Respondent/Counter-Petitioner.

_________________________________/

FAMILY LAW FINANCIAL AFFIDAVIT (SHORT FORM)
(Under $50,000 Individual Gross Annual Income)

I, [full legal name] ____________________, being sworn, certify that the following information is true:

1.  My gross monthly income before taxes and deductions: $__________

2.  My net monthly income (after taxes, Social Security, and court-ordered
    payments): $__________

3.  My assets: (list all real and personal property)

        Asset                            Value
        ________________________         $__________
        ________________________         $__________

4.  My liabilities: (list all debts)

        Creditor                        Monthly Payment    Balance Owed
        ____________________           $__________         $__________
        ____________________           $__________         $__________

5.  My monthly expenses: $__________

6.  My monthly child support arrears payment (current): $400.00
    Proposed arrears payment (after termination): $100.00

CERTIFICATION

I certify that a copy of this document was [e-filed / mailed] on ____________, 20__, to the other party listed below and to the Massachusetts Department of Revenue Child Support Enforcement Division.

                                    Respectfully submitted,

                                    ________________________________
                                    [Your full legal name], pro se
                                    Address: ________________________
                                    City, State, Zip: ________________
                                    Telephone: ______________________
                                    Email: __________________________

STATE OF FLORIDA
COUNTY OF __________

Sworn to (or affirmed) and subscribed before me this ____ day of ____________, 20__, by ____________________, who is personally known to me or who produced ____________________ as identification.

                                    ________________________________
                                    NOTARY PUBLIC or DEPUTY CLERK
                                    (Print, type, or stamp commissioned name of notary or clerk)