Financial Affidavit (Income Expenses And Financial Disclosure)

IN THE COURT OF COMMON PLEAS TUSCARAWAS COUNTY, OHIO CASE NO. _________________________ JUDGE: _________________________ _________________________________ SS# DOB__________ Plaintiff FINANCIAL AFFIDAVIT vs. _________________________________ SS# DOB___________ Defendant A. GENERAL VERIFIED FINANCIAL AFFIDAVITOF ________________________________________ (Instructions: This form mu be executed in fullst by each party. All blanks must be filled in as the testimony of the affiant. Values are to be verified or in the opinion of the affiant. The Affidavit must be filed with the first pleading of each party in every case or at an y hearing requesting spousal support, child support, or division of property - whichever first occurs . If additional space is needed, please attach extra pages.) 1. Date of marriage: __________________________________________________________ 2. Date separated: _____________________________________________________________ 3. Number of prior marriages, if any: ______________________________________________ 4. List of adults living in your household: Names Relationship to you Age __________________________________________________________________________ ____________________________________________________________ ____________ _________________________________________________________________________ 5. List children of this marriage: Names Date of Birth With whom are they living? _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Financial Affidavit Page 1 of 5 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 26. List names and addresses of your other children: Names Date of Birth With whom are they living? __________________________________________________________________________ __________________________________________________________________________ _________________________________________________________________________ 7. Have you filed bankruptcy within the last five (5) years? Yes No 8. If you have filed bankruptcy, please list Court: ____________________________________ Case No.: _________________________________ Your Attorney: _____________________________ B. INCOME 1. Current Employer: __________________________________________________________ Address: __________________________________________________________________ 2. Date of last full-time employment, if currently unemloyed: p _________________________ 3. Highest school grade completed, including college: ________________________________ 4. Do you hold a vocational or technical certificate?: ________________________________ What certificate?: ___________________________________________________________ 5. Current age: _______________________________________________________________ 6. Current health: Not Disabled Disabled Described disability: __________________________________________________ 7. Current gross income per month: $_______ Current net income per month: $_________ 8. How frequently are you paid?: _________________________________________________ 9. Other income (including rent, pensions, workers compensation, social security, unemployment benefits, royalties, interest, etc.): $________ per _____________ _______ 10. Preceding years 1040 adjusted gross income or W-2 (Attach tax return if available. If not available explain why not) ____________________________________________________ 11. Separate property brought to the marriage: Description: ; owned by: ; date acquired: ; net value when acquired: $ ; current net value: $ ; if not still owned, trace proceeds: _____________________________________________________________ Acquired by: _______________________________________________________________ (gift, inheritance, owned before marriage) 12. Pending inheritances: ________________________________________________________ Financial Affidavit Page 2 of 5 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 3 C. ASSETS OF THE PARTIES Item Ownership Fair Market Mtg./Loan Monthly (H, W, JT) Value Balance Payment 1. Residence at 2. Other Real Estate ____________ ____________ 3. Automobiles and motor vehicles ____________ ____________ ____________ ____________ 4. Number of rooms of furniture ____________ 5. Personal effects (jewelry, etc.) and collectibles ____________ 6. Tools ___________ 7. Bank Accounts (including Certificates of Deposit) ___________ ___________ ___________ ___________ ___________ 8. Stocks, Bonds ___________ ___________ ___________ 9. Life Insurance, cash surrender value ___________ ___________ 10. Trusts ___________ 11. Pension or other retirement benefits, including 401(K) or like ___________ 12. Miscellaneous ___________ ___________ ___________ ___________ Total Total Total Financial Affidavit Page 3 of 5 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 4 D. OTHER EXPENSES (List Monthly) 1. Rent or mortgage payment per month ______ ____________ 2. Real estate taxes and house insurance per month (if not included in mortgage) __________________ 3. Federal income tax, social security and medicare tax ______ ____________ 4. State income tax __________________ 5. City income tax __________________ 6. Other taxes __________________ 7. Other deductions (include and itemize) __________________________________________ __________________________________________ 8. Utilities: Electric __________________ Gas __________________ Garbage __________________ Water & Sewer __________________ TV-Cable __________________ Satellite/Dish __________________ Telephone __________________ Cell Phone __________________ __________________ __________________ 9. Automobile maintenance (license, insurance, gas, etc.) __________________ 10. Food for persons per month __________________ 11. Clothing: Self __________________ Dependents __________________ 12. School: Self __________________ Dependents __________________ 13. Daycare expenses (attach written verification): __________________ 14. Health insurance premium paid __________________ 15. Union dues __________________ 16. Child support paid __________________ 17. Spousal support paid to another spouse __________________ 18. Medical/dental expenses: Self __________________ Dependents __________________ 19. Insurance premiums not included above __________________ 20. Credit card accounts and other loans and/or d