Financial Disclosure Affidavit - County Of Summit
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4FINANCIAL DISCLOSURE / AFFIDAVIT
Instructions: You are required to answer the following questions accurately and completely. You must also sign
this affidavit in the presence of a Notary Public. The Summit County CSEA will provide a notary upon request.
You must also provide evidence supporting your financial or medical hardship or your request may be
denied.
I. PERSONAL INFORMATION
Party Represented (if applicant, enter “same”)
Name/Applicant
D.O.B.
Mailing Address
City
State
ZIP
Case No.
Phone
Message Phone (within 48 hours)
(
)
(
)
II. OTHER PERSONS LIVING IN HOUSEHOLD
Name
D.O.B
Relationship
Name
D.O.B
Relationship
1)
3)
2)
4)
III. MONTHLY INCOME/EMPLOYMENT INFORMATION
Spouse (or Parents if
Other Household
Type of Income
Applicant
applicant is a juvenile)
Members
Total
Employment (Gross)
Unemployment
Worker’s Comp.
Pension/Social Security
Child Support
Works First/TANF
Disability
Other
Employer’s Name
A. TOTAL
INCOME
$
Employer’s Address
Phone
(
)
IV. ALLOWABLE EXPENSES
V. TOTAL INCOME
Type of Expense
Amount
Child Support Paid Out
Total Income – Allowable Expenses = Adjusted Total Income
Child Care (if working only)
Transportation for Work
$
A. TOTAL INCOME
Insurance
$
-
B. EXPENSES
Medical/Dental
Medical & Associated Costs
C. ADJUSTED TOTAL INCOME
$
Of Caring for Infirm Family
Members
B. EXPENSES
$
VI. ASSET INFORMATION
Type of Asset
Describe / Length of Ownership / Make, Model, Year (where applicable)
Estimated Value
Real Estate / Home
Price:$
Date Purchased:
Amt. Owed:$
Stocks / Bonds / CD’s
Automobiles
Trucks / Boats / Motorcycles
Other Valuable Property
Cash on Hand
Money Owed to Applicant
Other
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