Affidavit Of Income And Expenses

IN THE FRANKLIN COUNTY COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS AND JUVENILE BRANCH Plaintiff/Petitioner v./and Case No. Judge Magistrate Defendant/Petitioner Instructions: This affidavit is required to be filed upon the filing of an action for divorce, legal separation or answer/counterclaim thereto pursuant to Local Domestic Rule 17. This affidavit is used to make complete disclosure of income, expenses and money owed. It is used to determine child and spousal support amounts. Do not leave any category blank. Write "none" where appropriate. If you do not know exact figures for any item, give your best estimate, and put "EST." If you need more space, add additional pages. AFFIDAVIT OF INCOME AND EXPENSES Affidavit of Date of marriage (Print Your Name) Date of separation Husband Yes No Wife Yes No SECTION I - INCOME Employed Employer Payroll address Payroll city, state, zip Scheduled paychecks per year A. 12 24 26 52 12 24 26 52 YEARLY INCOME, OVERTIME, COMMISSIONS AND BONUSES FOR PAST THREE YEARS Husband $ 3 years ago 2 years ago Last year 3 years ago 2 years ago Last year 20 20 20 20 20 20 $ $ $ $ $ $ Wife Base yearly income $ $ $ $ $ Yearly overtime, commissions and/or bonuses J-254 (Rev. 10-2010) Page 1 of 7 American LegalNet, Inc. www.FormsWorkFlow.com B. COMPUTATION OF CURRENT INCOME Husband Wife $ Base yearly income Average yearly overtime, commissions and/or bonuses over last 3 years (from part A) Unemployment compensation Disability benefits Workers' Compensation Social Security Other: Retirement benefits Social Security Other: Spousal support received Interest and dividend income (source) $ $ $ $ $ $ $ $ $ $ $ $ Other income (type and source) $ $ TOTAL YEARLY INCOME $ $ $ Supplemental Security Income (SSI) or public assistance Court-ordered child support that you receive for minor and/or dependent child(ren) not of the marriage or relationship $ $ $ $ J-254 (Rev. 10-2010) Page 2 of 7 American LegalNet, Inc. www.FormsWorkFlow.com SECTION II ­ CHILDREN AND HOUSEHOLD RESIDENTS Minor and/or dependent child(ren) who are adopted or born of this marriage or relationship: Name Date of birth Living with In addition to the above children there is/are in your household: adult(s) other minor and/or dependent child(ren). SECTION III ­ EXPENSES List monthly expenses below for your present household. A. MONTHLY HOUSING EXPENSES $ $ $ $ $ $ $ $ $ $ $ $ $ $ TOTAL MONTHLY : $ Rent or first mortgage (including taxes and insurance) Real estate taxes (if not included above) Real estate/homeowner's insurance (if not included above) Second mortgage/equity line of credit Utilities o o o o o o Electric Gas, fuel oil, propane Water and sewer Telephone Trash collection Cable/satellite television Cleaning, maintenance, repair Lawn service, snow removal Other: J-254 (Rev. 10-2010) Page 3 of 7 American LegalNet, Inc. www.FormsWorkFlow.com B. OTHER MONTHLY LIVING EXPENSES Food o o Groceries (including food, paper, cleaning products, toiletries, other) Restaurant Vehicle loans, leases Vehicle maintenance (oil, repair, license) Gasoline Parking, public transportation Clothes (other than children's) Dry cleaning, laundry Hair, nail care Other $ $ $ $ $ $ $ $ $ $ $ $ $ TOTAL MONTHLY C. MONTHLY CHILD-RELATED EXPENSES (for children of the marriage or relationship) $ $ $ $ $ $ $ $ $ $ TOTAL MONTHLY $ $ Transportation o o o o Clothing o o Personal grooming o o Cell phone Internet (if not included elsewhere) Other Work/education-related child care Other child care Unusual parenting time travel Special and unusual needs of child(ren) (not included elsewhere) Clothing School supplies Child(ren)'s allowances Extracurricular activities, lessons School lunches Other J-254 (Rev. 10-2010) Page 4 of 7 American LegalNet, Inc. www.FormsWorkFlow.com D. Life Auto INSURANCE PREMIUMS $ $ $ $ $ $ TOTAL MONTHLY $ Health Disability Renters/personal property (if not included in part A above) Other E. MONTHLY EDUCATION EXPENSES Tuition o o Self Child(ren) $ $ $ $ $ $ TOTAL MONTHLY: F. MONTHLY HEALTH CARE EXPENSES (not covered by insurance) $ $ $ $ $ $ TOTAL MONTHLY: G. MISCELLANEOUS MONTHLY EXPENSES $ $ $ $ $ $ $ $ Books, fees, other College loan repayment Other Physicians Dentists Optometrists/opticians Prescriptions Other Extraordinary obligations for other minor/handicapped child(ren) (not stepchildren) Child support for children who were not born of this marriage or relationship and were not adopted of this marriage Spousal support paid to former spouse(s) Subscriptions, books Entertainment Charitable contributions J-254 (Rev. 10-2010) Page 5 of 7 American LegalNet, Inc. www.FormsWorkFlow.com Memberships (associations, clubs) Travel, vacations Pets Gifts Bankruptcy payments Attorney fees Required deductions from wages (excluding taxes, Social Security and Medicare) (type) Additional taxes paid (not deducted from wages) (type) Other TOTAL MONTHLY: H. MONTHLY INSTALLMENT PAYMENTS (Do not repeat expenses already listed.) Examples: car, credit card, rent-to-own, cash advance payments To whom paid Purpose $ $ $ $ $ $ $ $ $ $ $ $ $ $ TOTAL MONTHLY: GRAND TOTAL MONTHLY EXPENSES (Sum of A through H): Balance due $ $ $ $ $ $ $ $ $ $ $ Monthly payment $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ J-254 (Rev. 10-2010) Page 6 of 7 American LegalNet, Inc. www.FormsWorkFlow.com OATH (Do not sign until notary is present.) I, (print name) , swear or affirm that I have read this document and, to the best of my knowledge and belief, the facts and information stated in this document are true, accurate and complete. I understand that if I do not tell the truth, I may be subject to penalties for perjury. Your Signature Sworn before me and signed in my presence this day of Notary Public My Commission Expires: , . J-254 (Rev. 10-2010) Page 7 of 7 American LegalNet, Inc. www.FormsWorkFlow.com