Form Ujs-304b Financial Affidavit Page 4

TOTAL LIABILITIES …..$_____________

ANTICIPATED INCOME (money or property you are expecting)

a. Total monies or income from sale of house or land, gifts, inheritance, allotments,

trust funds, lease money, etc………………………………………………………………$______________

When is the money/income expected? ______________________

Dated:

Signature of Person Filling out this Affidavit

(Sign only in front of notary public or clerk of courts.)

Sworn/affirmed before me this

day of

If notary, My Commission Expires ________________________

Notary Public \ Clerk of Courts

(SEAL)

 If you have children, you must complete the child support calculation. The DSS calculator is found at

 Attach your calculation of child support

Page 4 of 4

Form UJS-304B

Rev. 01/2015

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Parent category: Legal