IN THE SUPERIOR COURT OF COBB COUNTY STATE OF GEORGIA DOMESTIC RELATIONS FINANCIAL AFFIDAVIT. (1) Your Name: Your Age:
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1 IN THE SUPERIOR COURT OF COBB COUNTY STATE OF GEORGIA Petitioner: and Civil Action File No.: Respondent: DOMESTIC RELATIONS FINANCIAL AFFIDAVIT (1) Your Name: Your Age: Spouse s Name: Spouse s Age: Date of Marriage: Date of Separation: Names and birth dates of children for whom support is to be determined in this action: Name Date of Birth Resides with Names and birth dates of your other children: Name Date of Birth Resides with (2) SUMMARY OF YOUR INCOME AND NEEDS: (fill out this part after you complete pages 2-5) (A) Gross Monthly Income (from Item 3A below) (B) Net Monthly Income (from Item 3B below) (C) Average Monthly Expenses (Item 5A below) Monthly Payments to Creditors (Item 5B below) Total Monthly Expenses & Payments to Creditors (Item 5C below) Divorce Without Minor Children Packet Page 21 of 63
2 (3) (A) YOUR GROSS MONTHLY INCOME: (Complete this section or attach Child Support Schedule A). (All income must be entered based on monthly average regardless of date of receipt. Where applicable, income should be annualized) Salary or Wages ATTACH COPIES OF 2 MOST RECENT WAGE STATEMENTS Commissions, Fees & Tips Income from self-employment, partnership, close corporations and independent contracts (gross receipts minus ordinary and necessary expenses required to produce income) ATTACH SHEET ITEMIZING YOUR CALCULATIONS Rental income (gross receipts minus ordinary and necessary expenses required to produce income) ATTACH SHEET ITEMIZING YOUR CALCULATIONS Bonuses Overtime Payments Severance Pay Recurring Income from Pensions or Retirement Plans Interest and Dividends Trust income Income from Annuities Capital Gains Social Security Disability or Retirement Benefits Worker s Compensation Benefits Unemployment Benefits Judgments from Personal Injury or Other Civil Cases Gifts (cash or other gifts that can be converted to cash) Prizes & Lottery Winnings Alimony and maintenance from persons not in this case Assets which are used for support of family Fringe Benefits (if significantly reduce living expenses) Any Other Income (Do not include means-tested public assistance, such as TANF or food stamps.) Divorce Without Minor Children Packet Page 22 of 63
3 TOTAL Gross Monthly Income (also write in 2A on page one) (3)(B) Net Monthly Income From Employment (deducting only state and federal taxes and FICA) (also write in 2B on page one) Divorce Without Minor Children Packet Page 23 of 63
4 Separate Petitioner Separate Respondent Divorce Without Minor Children Packet Page 24 of 63
5 Separate Petitioner Separate Respondent Divorce Without Minor Children Packet Page 25 of 63
6 CHILDREN S EXPENSES Child Care (total monthly cost) Allowance School Tuition Children s Clothing Tutoring Diapers Private lessons (e.g., music, dance) Medical, Dental, Prescriptions (out-ofpocket uncovered expenses) School Supplies / Expenses Grooming / Hygiene Lunch Money Gifts from children to others Other Educational Expenses (list type & amount): Entertainment Activities (including extra-curricular, school, religious, cultural, etc.) Summer Camps OTHER INSURANCE Health Insurance Life Insurance Children s portion: Relationship of Beneficiary: Dental Insurance Disability Insurance Children s portion: Other Insurance (specify) Vision Insurance Children s portion: YOUR OTHER EXPENSES Dry Cleaning & Laundry Publications Clothing Dues, Clubs Medical / Dental / Prescription (out-ofpocket uncovered expenses) Religious & Charities Your Gifts (special holidays) Pet expenses Entertainment Alimony Paid to Former Spouse Recreational Expenses (e.g., fitness) Child Support Paid for other children Vacations Date of initial CS order: Divorce Without Minor Children Packet Page 26 of 63
7 Travel Expenses for Visitation Other (attach sheet to list) TOTAL ABOVE MONTHLY EXPENSES (also write on first line of 2C on page one) (5)(B) YOUR PAYMENTS & DEBTS TO CREDITORS To Whom Balance Due Monthly Payments (Please check one) Joint Petitioner Respondent Total Monthly Payments to Creditors (also write this total on line 2 of 2C on page one) (5)(C)TOTAL MONTHLY EXPENSES (Total Expenses from final line on page 5 + Total Monthly Payments to Creditors above) (also write this total on line 3 of 2C on page one) (Sign your name before Notary) Petitioner Respondent, Self-Represented Name (print or type): Address: Daytime Telephone Number: Sworn to and affirmed before me, this day of. NOTARY PUBLIC My commission expires: (Notary Seal) Divorce Without Minor Children Packet Page 27 of 63
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