IN THE FRANKLIN COUNTY COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS AND JUVENILE BRANCH

Transcription

1 Clear All Fields SAVE AS Print Dcument IN THE FRANKLIN COUNTY COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS AND JUVENILE BRANCH Case N. Plaintiff/Petitiner Judge v./and Magistrate Defendant/Petitiner Instructins: This affidavit is required t be filed upn the filing f an actin fr divrce, legal separatin r answer/cunterclaim theret pursuant t Lcal Dmestic Rule 17. This affidavit is used t make cmplete disclsure f incme, expenses and mney wed. It is used t determine child and spusal supprt amunts. D nt leave any categry blank. Write nne where apprpriate. If yu d nt knw exact figures fr any item, give yur best estimate, and put EST. If yu need mre space, add additinal pages. AFFIDAVIT OF INCOME AND EXPENSES Affidavit f (Print Yur Name) Date f marriage Date f separatin SECTION I - INCOME Yur Name Husband Yes Emplyed Wife N Yes Spuse's Name N Emplyer Payrll address Payrll city, state, zip 12 Scheduled paychecks per year A YEARLY INCOME, OVERTIME, COMMISSIONS AND BONUSES FOR PAST THREE YEARS Husband Base yearly incme Yearly vertime, cmmissins and/r bnuses Yur Name Spuse's Name Wife 3 years ag 2 years ag Last year 3 years ag 2 years ag Last year Page 1 f 7

2 B. COMPUTATION OF CURRENT INCOME Husband Yur Name Wife Spuse's Name Base yearly incme Average yearly vertime, cmmissins and/r bnuses ver last 3 years (frm part A) Unemplyment cmpensatin Disability benefits Wrkers Cmpensatin Scial Security : Retirement benefits Scial Security : Spusal supprt received Interest and dividend incme (surce) incme (type and surce) TOTAL YEARLY INCOME Supplemental Security Incme (SSI) r public assistance Curt-rdered child supprt that yu receive fr minr and/r dependent child(ren) nt f the marriage r relatinship J-254 (Rev. Page 2 f 7

3 SECTION II CHILDREN AND HOUSEHOLD RESIDENTS Minr and/r dependent child(ren) wh are adpted r brn f this marriage r relatinship: Name Date f birth Living with In additin t the abve children there is/are in yur husehld: adult(s) ther minr and/r dependent child(ren). SECTION III EXPENSES List mnthly expenses belw fr yur present husehld. A. MONTHLY HOUSING EXPENSES Rent r first mrtgage (including taxes and insurance) Real estate taxes (if nt included abve) Real estate/hmewner s insurance (if nt included abve) Secnd mrtgage/equity line f credit Utilities Electric Gas, fuel il, prpane Water and sewer Telephne Trash cllectin Cable/satellite televisin Cleaning, maintenance, repair Lawn service, snw remval : TOTAL MONTHLY : Page 3 f 7

4 B. OTHER MONTHLY LIVING EXPENSES Fd Grceries (including fd, paper, cleaning prducts, tiletries, ther) Restaurant Transprtatin Vehicle lans, leases Vehicle maintenance (il, repair, license) Gasline Parking, public transprtatin Clthes (ther than children s) Dry cleaning, laundry Clthing Persnal grming Hair, nail care Cell phne Internet (if nt included elsewhere) TOTAL MONTHLY C. MONTHLY CHILD-RELATED EXPENSES (fr children f the marriage r relatinship) Wrk/educatin-related child care child care Unusual parenting time travel Special and unusual needs f child(ren) (nt included elsewhere) Clthing Schl supplies Child(ren) s allwances Extracurricular activities, lessns Schl lunches TOTAL MONTHLY Page 4 f 7

5 D. INSURANCE PREMIUMS Life Aut Health Disability Renters/persnal prperty (if nt included in part A abve) TOTAL MONTHLY E. MONTHLY EDUCATION EXPENSES Tuitin Self Child(ren) Bks, fees, ther Cllege lan repayment F. MONTHLY HEALTH CARE EXPENSES (nt cvered by insurance) Physicians Dentists Optmetrists/pticians Prescriptins G. MISCELLANEOUS MONTHLY EXPENSES Extrardinary bligatins fr ther minr/handicapped child(ren) (nt stepchildren) Child supprt fr children wh were nt brn f this marriage r relatinship and were nt adpted f this marriage Spusal supprt paid t frmer spuse(s) Subscriptins, bks Entertainment Charitable cntributins J-254 (Rev. Page 5 f 7

6 Memberships (assciatins, clubs) Travel, vacatins Pets Gifts Bankruptcy payments Attrney fees Required deductins frm wages (excluding taxes, Scial Security and Medicare) (type) Additinal taxes paid (nt deducted frm wages) (type) H. MONTHLY INSTALLMENT PAYMENTS (D nt repeat expenses already listed.) Examples: car, credit card, rent-t-wn, cash advance payments T whm paid Purpse Balance due Mnthly payment GRAND TOTAL MONTHLY EXPENSES (Sum f A thrugh H): Page 6 f 7

7 OATH (D nt sign until ntary is present.) I, (print name), swear r affirm that I have read this dcument and, t the best f my knwledge and belief, the facts and infrmatin stated in this dcument are true, accurate and cmplete. I understand that if I d nt tell the truth, I may be subject t penalties fr perjury. Yur Signature Swrn befre me and signed in my presence this day f Ntary Public My Cmmissin Expires: Page 7 f 7,.