Income And Expense Statement With Affidavit

DR0706107 Post Decree Income and Expense Statement.doc COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS CUYAHOGA COUNTY, OHIO _________________________________________ Plaintiff _________________________________________ Address _________________________________________ City, State, Zip Code _________________________________________ Day Time Telephone Number _________________________________________ Attorney _________________________________________ Attorney Address _________________________________________ Attorney Telephone Vs _________________________________________ Defendant _________________________________________ Address _________________________________________ City, State, Zip Code _________________________________________ Day Time Telephone _________________________________________ Attorney _________________________________________ Attorney Address _________________________________________ Attorney Telephone : : : : : : : : : : : : Date of Divorce or Last Support Order: : _______________________________ : : Judge: ___________________________________ Case Number: ___________________________________ INCOME AND EXPENSE STATEMENT WITH AFFIDAVIT (Post-Decree) of: ______________________________ (Your name) NOTE: In accordance with Local Rule 19 of this Court, this Statement must be completed by each party prior to the time of hearing on any motion to modify child support or spousal support. You will be required to provide proof of income per Rule 19 and Ohio Revised Code §3119.05(A). You are under a continuing legal duty to file an updated version of this form if you learn of any additional information. ATTACH ADDITIONAL PAGES IF MORE SPACE IS NEEDED Initial: ________ Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com A. I. Information Required for Support Calculation: Minor or Dependent Children of this Marriage (Include adopted children and any child of the parties who is over 18 and still attending high school or is mentally or physically disabled) Child's Name Date of Birth Age Residing with ARE THERE ANY OTHER SUPPORT ORDERS ESTABLISHED FOR THESE CHILDREN? YES NO IF YES, ATTACH COPY OF ORDER AND PROVIDE THE FOLLOWING INFORMATION: DATE OF ORDER:_________ AMOUNT: $____________ CASE NUMBER: ________________ SETS NUMBER: ___________________ COURT (or agency) NAME: ______________________________ B. Other Minor Children Living in My Household. Child's Name Relationship to You Date of Birth Age $ $ $ Court Ordered Support Received C. Other Minor Children of Mine, NOT Living in My Household. Child's Name Residing with Date of Birth Age $ $ $ Court Ordered Support Paid II. Child Support Guideline Adjustment: Husband/Father (all figures per year) Wife/Mother (all figures per year) $ $ Total court ordered child support you pay for other children Total court ordered spousal support you pay to former spouse(s) Number of your other dependent children living with you from another marriage or relationship Court ordered child support you receive for the dependent child(ren) you indicated on line above Childcare expenses you pay for child(ren) of this marriage (employment or educational related) Local income taxes paid or rate of tax where you live or work Self-employment tax (5.6% of A.G.I.) Health insurance premium for children (family plan cost minus individual plan cost) A. $ $ $ $ $ $ $ % $ $ $ $ $ % III. Annual Income [as defined in Ohio Revised Code §3119.01(B)(5)]: Gross Annual Income from Employment (If not known, please estimate and write "EST" after each estimated figure.) Gross Annual Husband/Father Wife/Mother Employment Income $ Salary Wages $ Salary Wages Name(s) of Employer(s) Payroll Address(es) City, State, Zip Check the number of 12 24 26 52 12 24 26 52 paychecks per year Through date of: Through date of: Year-to-date Gross Income $ $ Prior Year's Tax Refund $ $ Benefits from Employment (Company Car, Club Memberships, Stock Options, etc.) 1. 2. 3. Total Annual Value of Benefits: $ $ $ $ Initial: ________ $ $ $ $ Page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com B. Annual Overtime, Commissions and Bonuses (If not known, please estimate and write "EST" after each estimated figure.) Husband/Father Base Income Overtime, Commissions & Bonuses Base Income Wife/Mother Overtime, Commissions & Bonuses LAST YEAR: 2 YEARS AGO: 3 YEARS AGO: $ $ $ Month Day Year $ $ $ $ $ $ $ $ $ $ $ $ $ THIS YEAR THROUGH C. Gross Annual Self-Employment Income (If not known, please estimate and write "EST" after each estimated figure.) Use gross annual figures for most recent full year. See Ohio Revised Code §3119.01(C)(13) Gross Annual Business Receipts Ordinary & Necessary Business Expenses Net Annual Business Income D. $ -$ =$ Company Name Company Address Nature of Business: Other Annual Income: Other income includes commissions (other than from employment), royalties, tips, rents, dividends, severance pay, interest, trust income, annuities, social security benefits (including retirement, disability and survivor benefits that are not need based), workers' compensation, unemployment insurance, spousal support actually received, recurring capital gains, etc. Also include military pay (including base pay, BAQ, BAS, specialty pay, variable housing allowance, training pay, combat pay, hazardous duty pay, etc). Need Based Assistance includes benefits received from a government-administered means-tested program such as Ohio works first, food stamps, SSI, disability financial assistance, etc. For complete definition of income see Ohio Revised Code Section 3119.01(C)(7). If exact amounts are not known, please estimate and write "EST" after each estimated figure. If more space is needed, attach extra pages. See additional pages: YES Husband/Father Other Income (Describe) Need Based Assistance $ $ $ $ $ $ $ $ Wife/Mother Other Income (Describe) Need Based Assistance $ $ $ $ $ $ $ $ Total Other Income $ Total Need Based Assistance $ Total Other Income $ Total Need Based Assistance $ E. Available Monthly Income Wife/Mother Average Monthly Deductions Total Gross Fed/State/Local Annual Income $ Taxes Social Security Medicare Health Insurance Union Dues Pensions IRAs/401(k)s Support Orders Other: Total Average Deductions Husband/Father Average Monthly Deductions Total Gross Fed/State/Local Annual Income $ Taxes Social Security Medicare Health Insurance Union Dues Pensions IRAs/401(k)s Support Orders Other: Total Average Deductions $ Divide Gross Annual By 12 $ Divide Gross Annual By 12 $ $