Financial Disclosure Affidavit - County Of Summit Page 2
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1
2
3
4Checking Acct. Balance
Savings/MM Acct. Balance
$
D. TOTAL ASSETS
VII. MONTHLY LIABILITIES/OTHER EXPENSES
VIII. GRAND TOTALS
Type of Liability
Amount
Rent / Mortgage
C. ADJ. TOTAL INCOME
Food
Electric
D. TOTAL ASSETS
Gas
Fuel
E. LIABILITIES & OTHER
Telephone
Cable
Water / Sewer / Trash
Credit Cards
Loans
Taxes Owed
Other
E. LIABILITIES & OTHER
EXPENSE
I, _______________________________________________________(affiant) being duly sworn, say:
I hereby certify that the information I have provided on this financial disclosure form is true to the best of my
knowledge.
Affiant’s Signature
Date
Notary Public/Individual duly authorized to administer oath:
Subscribed and duly sworn before me according to law, by the above named applicant this
day of
______
,
, at _______________________, County of
_______________________
_______
___________________________
and State of
.
_________________
Signature of person administering oath
Title
Please attach as many pages as needed describing your specific reason for requesting this
waiver or compromise. Remember, you must attach evidence supporting this request or your
request could be denied.
If your request relates to medical disability, you must describe why you are unable to work,
when and how you became unable to work, and attach a written statement from your doctor which
contains the following information: the name of the medical condition which prevents you from
working or which limits your ability to work; the date upon which you became unable to work; and
the date, if any, upon which you should be able to return to work.
If your request is due to incarceration, you must state the month and year that your incarceration
began and ended, the location and date of all convictions, and the name of all convictions.
If your request relates to employment issues, you must describe all obstacles to full-time
employment.
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