Beruflich Dokumente
Kultur Dokumente
CIRCUIT
IN AND FOR HILLSBOROUGH COUNTY, STATE OF FLORIDA
FAMILY LAW DIVISION
MARGO J. HART,
PetitionerlWife, CASE NO.: 04-009083
and
I, NORMAN B. HART, JR., being duly sworn, certify that the following information ts~
true:
MyOccupatidn: C()/1sultant
__ Check here if unemployed and explain on a separate sheet your efforts to find
employment.
All amounts must be MONTHLY. See the instructions with this form to figure out money
amounts for anything separately that is NOT paid monthly. Attach more paper, if needed.
Items included under "other" should be listed with separate dollar amounts.
. ..
11. Monthly rental income (gross receipts minus ordinary and $0.00
necessary expenses required to produce income) (Attach sheet I
16. Any other income of a recurring nature (list source) $O.pO . .'
·
. .
" ....
19. Monthly FICA or self-employment taxes ,$226.8.9,. ••
. ....
25a. from this case: .... 2i.'. ....•.•.• :c .. < ...:. . '.' :': .. ' .. i : . '
SQcQq
," ... ' , :. .
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Other: $0',00
Other:
••.. '.. .•.•• ...•..••.. •.••
· c ........;~~:;r
....
..: ....
31. SURPLUS/DEFICIT
A. ASSETS:
DESCRIPTION OF ITEM(S). List a description of each separate item owned by you (and!or
your spouse, if this is a petition for dissolution of marriage). Check the box next to any
asset(s) which you are requesting the judge award to you.
husband wife
.'.
Automobiles
'.,
,.$Q:QO . . '........
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Other personal property
"'J ............•
Retirement plans (Profit Sharing, Pension,
.
$O.0Q
IRA , 401 (k)s, etc.) .... ........•
. . . ·. · . · · · i : < ' . A
• ..............
..
".
$0.00 :.:
B. LIABILITIES:
DESCRIPTION OF ITEM(S). List a description of each separate debt owed by you (and/or
your spouse, if this is a petition for dissolution of marriage). Check the box next to any
debt(s) for which you believe you should be responsible.
husband wife
.. : ..... .
1.·:$q~9(}· .'.
Auto loans 1
.. :. . .......
Capital VISA
. .":"
Capital Gold . . $?,~?§~qO·.·:· '. . . :. . . :. ;.. '.
Capital Mastercard
.:: ... :.........: ." '.'
Wachovia
'. ":
Other: Brandon Hospital $a,52t~oO '. ...•... '
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Emergency Doctor (approximate)
Cardiologist (approximate)
Ambulance (approximate)
Contingent Assets:
husband wife
..... ,
item:
Contingent Liabilities:
husband wife
.:
item:
item: $o.()O ..
.. ... .... . .
..
. . . . . .,
item: .$Q.QOi,. . ,,< ........ ...•......
Total Contingent Liabilities
A Child Support Guidelines Worksheet ( ) is ("') is not being filed in this case.
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I understand that I am swearing or affirming under oath to the truthfulness of the
claims made in this affidavit and that the punishment for knowingly making a false
statement includes fines and/or imprisonment.
Date
STATE OF FLORIDA
COUNTY OF HILLSBOROUGH
I hereby acknowledge that the foregoing financial affidavit was executed by NORMAN B.
HART, JR., this ~cl day of August, 2004, ( ) who is personally known to me or (~) who
produced Florida Driver's License as identification and who (~) did ( ) did not take an oath.
CERTIFICATE OF SERVICE
I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by
[.1'] regular U.S. Mail [ ] facsimile [ ] hand delivery to GLENN E. BROWN, ESQUIRE, 2529
West Busch Boulevard, Suite 600, Tampa, Florida 33618, this 3rd day of August, 2004.
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