Domestic Relations Affidavit
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1 Domestic Relations Affidavit IN THE JUDICIAL DISTRICT COUNTY, KANSAS IN THE MATTER OF and Case No. DOMESTIC RELATIONS AFFIDAVIT OF (name 1. Residence XXX-XX- Birth Month/Year Social Security Number Telephone 2. Residence XXX-XX- Birth Month/Year Social Security Number Telephone 3. Date of Marriage: 4. Number of Marriages: 5. Number of children of the relationship: 6. Names, Social Security Numbers, the month and year of each child s birth and ages of minor children of the relationship: Name Social Security Number Birth Age Custodian XXX-XX- Month /Year 7. Names, Social Security Numbers, and ages of minor children of previous relationships and facts as to custody and support payments paid or received, if any. Rev. 09/2016 by KSJC 1 of 7
2 Social Support Paid Name Security No. Age Custodian Payment or Rec d XXX-XX- 8. is employed by is employed by (Name and address of employer with monthly income as follows: A. Wage Earner 1. Gross Income 2. Other Income 3. Subtotal Gross Income 4. Federal Withholding (Claiming exemptions 5. Federal Income Tax 6. OASDHI 7. Kansas Withholding 8. Subtotal Deductions 9. Net Income B. Self-Employed 1. Gross Income from self-employment 2. Other Income 3. Subtotal Gross Income 4. Reasonable Business Expenses (Itemize on attached exhibit 5. Self-Employment Tax 6. Estimated Tax Payments (Claim exemptions 7. Federal Income Tax Rev. 09/2016 by KSJC 2 of 7
3 8. Kansas Withholding 9. Subtotal Deductions 10. Net Income (Line B.3. minus Line B.9. Pay period: 9. The liquid assets of the parties are: Joint or Individual Item Amount (Specify A. Checking Accounts (Do not list account numbers: B. Savings Accounts (Do not list account numbers: C. Cash D. Other 10. The monthly expenses of each party are: (Please indicate with an asterisk all figures which are estimates rather than actual figures taken from records. A. Item (Actual or Estimated (Actual or Estimated 1. Rent (if applicable* 2. Food 3. Utilities/services: Trash Service Newspaper Telephone Mobile Phone Cable Rev. 09/2016 by KSJC 3 of 7
4 Gas Water Lights Other 4. Insurance: Life Health Car House/Rental Other 5. Medical and dental 6. Prescriptions drugs 7. Child care (work-related 8. Child care (non-work-related 9. Clothing 10. School expenses 11. Hair cuts and beauty 12. Car repair 13. Gas and oil 14. Personal property tax Item (Actual or Estimated (Actual or Estimated 15. Miscellaneous (Specify 16. Debt Payments (Specify Total *Show house payments, mortgage payments, etc., in Section 10.B. Rev. 09/2016 by KSJC 4 of 7
5 B. Monthly payments to banks, loan companies or on credit accounts: (Indicate actual or estimated monetary amount in each column, use asterisk for secured. DO NOT LIST ANY PAYMENTS INCLUDED IN PART 10.A ABOVE. When Amount of Date of Responsibility Creditor Incurred Payment Last Payment Balance Subtotal of Payments Total C. Total Living Expenses (Actual or Estimated (Actual or Estimated 1. Total funds available to Petitioner and Respondent (from No Total needed (from No. 10.A and B 3. Net Balance 4. Projected child support D. Payments or contributions received, or paid, for support of others. Specify source and amount. Source (+/- (+/- (+/- (+/- 11. How much does the party who provides health care pay for family coverage? per. How much does it cost the provider to furnish health insurance only on the provider? per. Rev. 09/2016 by KSJC 5 of 7
6 FURNISH THE FOLLOWING INFORMATION IF APPLICABLE. 12. Income and financial resources of children. Income/Resources Amount 13. Child support adjustments requested. Long Distance Parenting Time Costs Parenting Time Adjustments Income Tax Considerations Special Needs Support Beyond Age of Majority Overall Financial Condition 14. All other personal property including retirement benefits (including but not limited to qualified plans such as profit-sharing, pension, IRA, 401(k, or other savings-type employee benefits, nonqualified plans, and deferred income plans, and ownership thereof (joint or individual, including policies of insurance, identified as to nature or description, ownership (joint or individual, and actual or estimated value. Amount Joint or Individual (Specify THE FOLLOWING NEED NOT BE FURNISHED IN POST JUDGMENT PROCEDURES. 15. List real property identified as to description, ownership (joint or individual and actual or estimated value. Property Description Ownership Actual/Estimated Value Rev. 09/2016 by KSJC 6 of 7
7 16. Identify the property, if any, acquired by each of the parties prior to marriage or acquired during marriage by a will or inheritance. Source of Actual/ Property Description Ownership Ownership Estimated Value 17. List debt obligations, including maintenance, not listed in Section 10.A or 10.B above, identified as to name or names of obligor or obligors and obligees, balance due and rate at which payable; and, if secured, identify the encumbered property. Debt Balance Payment Encumbered Obligation Obligor Obligee Due Rate Property 18. List health insurance coverage and the right, pursuant to ERISA , 29 U.S.C (1986, to continued coverage by the spouse who is not a member of the covered employee group. Health Insurance COBRA Continuation Yes No Unknown I declare under penalty of perjury under the laws of the State of Kansas that the foregoing is true, correct and complete. Executed on the day of, 20. Rev. 09/2016 by KSJC 7 of 7 Name (Print: Signature:
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