* Delete Where Applicable

WESTERN AUSTRALIA MAGISTRATES COURT Civil Judgments Enforcement Regulations 2005 LOCATION: Regulation 17 FORM 38 – STATEMENT OF FINANCIAL AFFAIRS Court ref number:

Name: Judgment creditor Name: Lawyer

File ref number Contact/address details

Name: Judgment debtor Address:

* Delete where applicable

1. *I am employed as a by Business address Telephone number Mobile phone number 2. *I am unemployed/a pensioner and registered with Centrelink at 3. I am single/married/separated. 4. *I have/do not have a dependant *wife/husband/defacto spouse and dependant children. 5. My *weekly/fortnightly/monthly income and expenditure is as follows: (whole dollars only)

INCOME EXPENDITURE

Wage/salary/benefit (net): Rent/board $ Self $ Mortgage payment $ Spouse +$ Child support for dependants $ Defacto +$ Food $ Total = $ Electricity/gas $ Telephone $ Water $ Income from investments $ Rates and taxes $ Other income $ Clothing $ Medical $ Vehicle expenses $ School expenses $ Day care $ Bus/train/taxi fares $ Other court orders $ $ Credit card payments $ Loan payments $ Other payments ( ) $

TOTAL INCOME $ TOTAL EXPENDITURE $

PTO 6. My assets and liabilities are as follows: (whole dollars only)

ASSETS House/unit/other real property (give addresses) $ $ Motor vehicles (car, utility, motor cycle, truck etc): Make and model Reg number $ Make and model Reg number $ Make and model Reg number $ Home contents: TV yes/no $ Video recorder yes/no $ DVD recorder yes/no $ Furniture yes/no $ Dishwasher yes/no $ Microwave yes/no $ Fridge yes/no $ Washing machine yes/no $ Collection of coins, stamps, etc. $ Other collectables $ Interest in business or company $ Other assets $ Money owed to me $ Money in bank, building society and/or credit union: Self $ Spouse +$ Defacto +$ Total = $

TOTAL OF ASSETS $

LIABILITIES Mortgage to Balance $ Other to Balance $ Outstanding fines – Time for Payment Order Balance $ Credit cards Balance $ Personal loan Balance $ Other debts owing (give details) Balance $ Balance $ Balance $ TOTAL OF LIABILITIES $

Date: Signature: ......

Form 38 Version 3 January 2011