IN THE CIRCUn ~OURT OF THE THIRTEENTH JUDICIAt.

CIRCUIT
IN AND FOR HILLSBOROUGH COUNTY, STATE OF FLORIDA
FAMILY LAW DIVISION

IN RE: THE MARRIAGE OF

MARGO J. HART,
PetitionerlWife, CASE NO.: 04-009083

and

NORMAN B. HART, JR., DIVISION: D

RespondenYHusband
______________________ ~I

FAMILY LAW FINANCIAL AFFIDAVIT (short form)

(Under $50,000.00 Annual Gross Income)

I, NORMAN B. HART, JR., being duly sworn, certify that the following information ts~
true:

MyOccupatidn: C()/1sultant

Pay Rate: e~~f;,:·(\"~5;•.~*~k.·ii·.·.•· .·• •· .·. •~(:".;· · · (·. •·.•··\·)··;bi~~e~~ly­

·(:}~.~.rnl-J1'l9r:l~hIY· .(~JJ1'lo.,,~~:ly .
·f.)g~ij~r:'

__ Check here if unemployed and explain on a separate sheet your efforts to find
employment.

SECTION I. PRESENT MONTHLY GROSS INCOME:

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.

1. Monthly gross salary or wages *Approximate

2. Monthly bonuses, commissions, allowances, overtime, tips, and

similar payments

3. Monthly business income from sources such as self-employment,

partnerships, close corporations, and/or independent contracts
(gross receipts minus ordinary and necessary expenses required to
produce income) (Attach sheet itemizing such income and
expenses.)

4. Monthly disability benefits/SSI

5. Monthly Workers' Compensation

6. Monthly Unemployment Compensation

7. Monthly pension, retirement, or annuity payments

8. Monthly Social Security benefits J'$b.;C>p·· . .,' ·

9. Monthly alimony actually received

. '.' . ....
9a. From this case: < ...•. .' ., ". . ...
$J;tOO
,
....
9b. From other case(s): .... .. " $0.00
·c. .. '.
. .' .'

Add 9a. And 9b. $0.00 .

.

10. Monthly interest and dividends $0.00 . '

'. •

. ..

11. Monthly rental income (gross receipts minus ordinary and $0.00
necessary expenses required to produce income) (Attach sheet I

itemizing such income and expense items.) .-- :.

·

12. Monthly income from royalties, trusts, or estates $0.00

.'

13. Monthly reimbursed expenses and in-kind payments to the $0.00

extent that they reduce personal living expenses . .
' ". :..
..
14. Monthly gains derived from dealing in property (not including $0.00
nonrecurring gains) '. .!.. . .. ' '. .

", ' . :..

15. Any other income of a recurring nature (list source) $(foO:. ..
. ...... .'

16. Any other income of a recurring nature (list source) $O.pO . .'
·

. .

17. PRESENT MONTHLY GROSS INCOME TOTAL: ,·$3,~59.00

(Add lines 1-16) ':
:

PRESENT MONTHLY DEDUCTIONS:

.<, •...'...
18. Monthly federal, state, and local income a.:~il.ih9St~tus· ····8· $531 •. 60' ....
tax (corrected for filing status and allowable b. -Numberof
dependents and income tax liabilities) dep~rlqents' ..••.. >
.... clainied _1_ .'
' . . ' . .
,'
.....

" ....
19. Monthly FICA or self-employment taxes ,$226.8.9,. ••

. ....

20. Monthly Medicare payments $53.. 00 ..

.
..
21. Monthly mandatory union dues ~o.{OQ··· •. •. . . '. . .
. ... • ... .'

22. Monthly mandatory retirement payments "$0.00, ;,:.

, '. ·
. .
·
23. Monthly health insurance payments (including dental insurance), $O·og .'

excluding portion paid for any minor children of this relationship .. :

.' .'" ',.>
....
24. Monthly court-ordered child support actually paid for children $0.00'
'.' .......

from another relationship ,. "C

.'
,i .

25. Monthly court-ordered alimony actually paid

25a. from this case: .... 2i.'. ....•.•.• :c .. < ...:. . '.' :': .. ' .. i : . '
SQcQq
," ... ' , :. .

25b.from other case(s): .... , $mOO

.: ".
<: ..
..,
Add 25a and 25b $0.00 '.'

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Other: $0',00
Other:
••.. '.. .•.•• ...•..••.. •.••
· c ........;~~:;r

Other: ......... ..~/y.

.... .... ..•... . . I e :,.: .....'. . '~ ....•.. ~ '.' •.' •....

·... ;·.~.f·:. ;. ... 2.' "'..: . . •.

Column Totals: Column Totals: ;::':;Z:'i. ..•..•...•...• .,':.;,i .. ;

28. TOTAL MONTHLY EXPENSES

....

29. TOTAL PRESENT MONTHLY NET INCOME (from line 27 of .$2,848.15

SECTION I. INCOME) .... . . .
. •...
.

30. TOTAL MONTHLY EXPENSES (from line 28 above) $3,813:42

..: ....

31. SURPLUS/DEFICIT

SECTION III: ASSETS AND LIABILITIES

Use the nonmarital column only if this is a petition for dissolution of marriage and you believe
an item is "nonmarital," meaning it belongs to only one of you and should not be divided.
You should indicate to whom you believe the item(s) or debt belongs. (Typically, you will only
use this column if property! debt was owned!owed by one spouse before the marriage. See
the instructions with this form and section 61.075(1), Florida Statutes, for definitions of
"marital" and "nonmarital" assets and liabilities.)

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.

ITEM: Current Fair Market Nonmarital

Value

husband wife
.'.

Cash (on hand) $pb~Qo ........ ;. ..

Cash (in banks or credit unions)
1:9;000" ":'. . . .;..
Stocks, Bonds, Notes :::r:.•.;-:.~:;",':.: •... , ...',.,'.' .. :,;. . ,
,

Real estate: (Home)

(Other) ."" .;.

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
• ..............
..
".

Other .... :::..:: .i·' ;'i;: . : . . ..

........... . ::.:.:c" :'. . . .'.
Furniture ,~\J·l.I"Ji.· ". ..... ... i.: .
.
Cash taken by Wife (Approximate) $60, 000. on .
. . ...
$'0.'00 . ...
$0.00

$0.00 :.:

Check here if additional pages are attached.

Total Assets (add column B)

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.

ITEM: Current Amount Nonmarital

O'4fed

husband wife

Mortgages on real estate $7.1,78~.OO. ....

.. : ..... .
1.·:$q~9(}· .'.
Auto loans 1
.. :. . .......

Charge/credit card accounts

Capital VISA
. .":"
Capital Gold . . $?,~?§~qO·.·:· '. . . :. . . :. ;.. '.
Capital Mastercard
.:: ... :.........: ." '.'

Shell Oil I': ;~fIlJ ....

I· . ·:··· •. · "};iT )::'::">:::'> .:. ..... <..
Chevron

Wachovia
'. ":
Other: Brandon Hospital $a,52t~oO '. ...•... '

Page -5-
Emergency Doctor (approximate)

Cardiologist (approximate)

Lakeland Regional Hospital

Ambulance (approximate)

Helicopter Ambulance (approximate)

, ..
' '

Attending Physician $1,qPO.qo ",,'" ,',,'

,,',' ,',", "'.'

Check here if additional pages are attached.

Total Debts (add column B) $151,397.00 '

C. CONTINGENT ASSETS AND LIABILITIES

Contingent Assets:

ITEM: Possible Value Nonmarital

husband wife
..... ,

item: $ 0 . 0 0 . < . • . ,,'

item:

item:

Total Contingent Assets

Contingent Liabilities:

ITEM: Possible Amount Nonmarital

Owed

husband wife
.:

item:

item: $o.()O ..
.. ... .... . .
..
. . . . . .,
item: .$Q.QOi,. . ,,< ........ ...•......
Total Contingent Liabilities

SECTION IV: CHILD SUPPORT GUIDELINES WORKSHEET

A Child Support Guidelines Worksheet ( ) is ("') is not being filed in this case.

Page -6-
 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.

~~.~ BAm AAHALL

~l'i;&'~ MY COMMISSION # DD.289927
Seal: 1f~7 EXPIRES: May ~7, 2008
'~P,f.,~,~ Bonded Thru Notary Public Underwriters
NOTARY PUBLIC

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.

BRETT R. RAHALL, ESQUIRE

Rahall & Schaffer, P.A.
120 South Willow Avenue
Tampa, Florida 33606
(813) 258-8888
FBN: 896901
Attqrneys for Husband

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