DOMESTIC RELATIONS FINANCIAL AFFIDAVIT - DIVORCE. Date of Separation:

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Transcription:

IN THE SUPERIOR COURT OF COUNTY Plaintiff, vs. Defendant. Civil Action No. DOMESTIC RELATIONS FINANCIAL AFFIDAVIT - DIVORCE 1. AFFIANT'S NAME: Spouse s Name: Age: Age: Date of Marriage: Date of Separation: Names and birth dates of children whom support is to be determined in this action: Name Year of Birth Resides with: Names and birth dates of affiant's other children: Name Year of Birth Resides with: 2. SUMMARY OF AFFIANT S INCOME AND NEEDS (a) Gross monthly income (from item 3A) 0 (b) Net monthly income (from item 3C) 0 (c) Average monthly expenses (from item 5A) 0 Monthly payments to creditors (from item 5B) 0 Total monthly expenses and payments 0 to creditors (from item 5C) 3(A). AFFIANT S GROSS MONTHLY INCOME (complete this section or attach Child Support Schedule A) (All income must be entered based on monthly average regardless of state of receipt.)

Salary or Wages 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) GROSS MONTHLY INCOME 0 A. Affiant's Net monthly income from employment (deducting only state and federal taxes and FICA) Affiant s pay period (i.e. weekly, monthly, etc.) Number of exemptions claimed

4. ASSETS If you claim or agree that all or part of an asset is non-marital, indicate the non-marital portion under the appropriate spouse s column and state the amount and the basis: pre-marital, gift, inheritance, source of funds, etc.). Description Value Separate Asset of Husband Separate Asset of Wife Basis of Claim Cash: Stocks, bonds: CD/Money Market: Bank accounts: (list each account) Retirement Pensions, 401K, IRA or Profit Sharing: Money owed you: Real Estate Home: debt owed: Other: debt owed: Automobile Vehicle 1: debt owed: Vehicle 2: debt owed: Life insurance (net cash value) Furniture/Furnishings: Jewelry: Collectibles

Other Assets TOTAL ASSETS 0 0 0 5. A. AVERAGE MONTHLY EXPENSES HOUSEHOLD Mortgage or rent payments: Property taxes: Homeowners/Renter Insurance: Electricity: Water: Garbage & Sewer: Telephone: Residential Line: Cellular Telephone: Gas: Repairs & maintenance: Lawn Care: Pest control: Cable TV: Misc. household/grocery items: Meals outside of home: Other: AUTOMOBILE Repairs Tags & license Insurance CHILDREN EXPENSES Child care School tuition School supplies/expenses Lunch Money Allowance Clothing Diapers Medical, dental prescription Grooming/hygiene Gifts Entertainment Activities OTHER INSURANCE Health Gasoline & oil Child(ren)'s portion: Repairs Dental: Auto Tags & license Child(ren)'s portion: Insurance OTHER VEHICLES (Boats, trailers, RVs, etc.) Gasoline & oil Vision: Child(ren)'s portion: Life: Relation of Beneficiary:

OTHER INSURANCE(cont.) Disability Other(Specify): Recreational Expenses (eg., fitness) Vacations Travel Expenses for Visitation Publications Dues, clubs AFFIANT S OTHER EXPENSES Dry cleaning and laundry Clothing Medical, dental, prescription (out of pocket/uncovered expenses) Affiant s gifts (special holidays) Religious and charities Pet Expenses Alimony paid to former spouse Child Support paid for other children Date of Initial Order Other (attach sheet) Entertainment B. PAYMENTS TO CREDITORS TOTAL AVERAGE MONTHLY EXPENSES 0 To whom: Monthly Payment Balance Due Joint Plaintiff Defendant (please check one) TOTAL MONTHLY PAYMENT TO CREDITORS 0 (C). GRAND TOTAL MONTHLY EXPENSES 0

This day of, 2016. Sworn to and subscribed before me this day of, 2016. Affiant Notary Public, County, Ga. My Commission expires

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