Financial Affidavit - Local Rule 11.02 {CV-AFF5}

IN THE CIRCUIT COURT OF THE 22ND JUDICIAL CIRCUIT McHENRY COUNTY, ILLINOIS IN RE: The Marriage of: Custody of: ) ) ) ) ) ) ) ) Support of: _________________________________ Petitioner and _________________________________ Respondent Case Number:_______________________________ FINANCIAL AFFIDAVIT - LOCAL RULE 11.02 (LAST THREE (3) PAY STUBS AND LAST TWO (2) TAX RETURNS MUST ALSO BE PRODUCED) Affiant, _______________________________________, having been duly sworn, upon oath, states that the information contained herein is true and correct as of ____________________________________, 20 ____. Name: __________________________________ Address: ________________________________ _________________________________________ Date of Marriage: _________________________ (mmddyyyy) Telephone No: ( ______ ) _______________________ Petitioner Date of Birth ________________(mmddyyyy) Respondent Date of Birth _______________(mmddyyyy) Date of Dissolution of Marriage (if applicable) __________________ (mmddyyyy) Minor and/or Dependent Children of this Marriage: NAME Date of Birth (mmddyyyy) Currently Living With (Attach additional page(s) as needed) Current Employer: Self Employment: Other Employment Address: Address: Address: Check if unemployed Number of Paychecks per year: (Please Check Box) 12 24 26 52 Other_________ CV-AFF5 Pursuant to Local Court Rule 11.02 revised 4/1/08 Page 1 of 7 American LegalNet, Inc. www.FormsWorkFlow.com Number of Exemptions claimed: _________________ Number of Dependents claimed: _________________ Gross Income from all sources last year: ___________________________________________________ Gross Income from all sources this year through _______________________: $ ___________________ STATEMENT OF INCOME Gross Monthly Income Salary/Wages/Base Pay Overtime/Commission Bonus Draw Pension and Retirement Benefits Annuity Interest income Dividend income Trust income Social Security Unemployment benefits Disability payment Worker's Compensation Public Aid/Food Stamps Investment income Rental income Business income (including non-taxable distributions Partnership income Royalty income Fellowship/stipends Other income (specify): TOTAL GROSS MONTHLY INCOME: $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ ____________________ $ ______________ ADDITIONAL CASH FLOW (Monthly) Spousal support received (specify) Pursuant to a prior judgment or order in another case Pursuant to a prior judgment or order in this case Voluntarily paid in this case Child Support received (specify) Pursuant to a prior judgment or order in another case Pursuant to a prior judgment or order in this case Voluntarily paid in this case TOTAL ADDITIONAL CASH FLOW: CV-AFF5 Pursuant to Local Court Rule 11.02 revised 4/1/08 Page 2 of 7 American LegalNet, Inc. www.FormsWorkFlow.com $ $ $ $ $ $ $ $ $________________ $ _____________ REQUIRED MONTHLY DEDUCTIONS Federal Tax (based on _________ exemptions State Tax (based on _________ exemptions FICA ( or Social Security equivalent) Medicare Tax Mandatory retirement contributions required by law or as a condition of employment Union Dues (Name of Union: _________________) Health/hospitalization Premiums Prior obligation(s) of support actually paid pursuant to Court order Other (specify): Total Required Deductions from Income: NET MONTHLY INCOME: $ $ $ $ $ $ $ $ $ $ $ $ _________________ $ ____________ STATEMENT OF MONTHLY LIVING EXPENSES 1. Household a. Mortgage or rent (specify) b. Home equity loan payment c. Real estate taxes, assessments d. Homeowners or renters insurance e. Heat/fuel f. Electricity g. Telephone (include long distance) h. Water and Sewer i. Refuse removal j. Laundry/dry cleaning k. Maid/cleaning service l. Furniture and appliance repair/replacement m. Lawn and garden care/snow removal n. Food (groceries, household supplies, etc.) o. Liquor, beer, wine, etc. p. Other (specify) SUBTOTAL HOUSEHOLD EXPENSES 2. a. b. c. d. e. Transportation Fuel Repairs/maintenance Insurance/license/city stickers Payments/replacement Other (specify) SUBTOTAL TRANSPORATION EXPENSES $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ ________________ $ ____________ $ $ $ $ $ $ _______________ $ ____________ CV-AFF5 Pursuant to Local Court Rule 11.02 revised 4/1/08 Page 3 of 7 American LegalNet, Inc. www.FormsWorkFlow.com 3. a. b. c. Personal Clothing Grooming Medical (after insurance proceeds/reimbursement (1) Doctor (2) Dentist (3) Optical (4) Medication d. Insurance (1) Life ­ Term/Whole (specify) (2) Medical/Hospitalization (3) Dental/optical e. Other (specify) SUBTOTAL PERSONAL EXPENSES: 4. a. b. c. d. e. f. Miscellaneous: Clubs/social obligations/entertainment Newspapers, magazines, books Gifts Donations, church or religious affiliations Vacations Other (specify) SUBTOTAL MISCELLANEOUS EXPENSES $ $ $ $ $ $ $ $ $ $ $ $ $ _______________ $ ______________ $ $ $ $ $ $ $ ______________ $ ______________ 5. a. b. c. Expenses of Minor and/or Dependent Children of this Marriage: Clothing $ Grooming $ Education (1) Tuition $ (2) Books/Fees $ (3) Lunches $ (4) Transportation $ (5) Medication $ d. Medical (after insurance proceeds/reimbursement (1) Doctor $ (2) Dentist $ (3) Optical $ (4) Medication $ e. Allowance $ f. Child care/After-school care $ g. Sitters $ h. Lesson and supplies $ i. Clubs/Summer Camps $ j. Vacation $ k. Entertainment $ l. Other (specify) $ SUBTOTAL CHILDREN'S EXPENSES $ _______________ $ ______________ CV-AFF5 Pursuant to Local Court Rule 11.02 revised 4/1/08 Page 4 of 7 American LegalNet, Inc. www.FormsWorkFlow.com TOTAL MONTHLY LIVING EXPENSES STATEMENT OF LIABILITIES: CREDITOR'S NAME PAYMENT FOR $ ______________ $ _____________ BALANCE DUE $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ TOTAL LIABILITIES $ ___________________ TOTAL MONTLY DE BT SERVICE (Attach additional page(s) as needed) MONTHLY PAYMENT $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ ____________________ STATEMENT OF ASSETS Marital Residence and Other Real Estate 1. Marital Residence at: 2. 3, 4, TOTAL REAL ESTATE Valuation Date: ______________ (mmddyyy) Market Value $ $ $ $ $ __________________ Debt $ $ $ $ $ ___________________ Debt $ $ $ $ $ $ $ ___________________ Cars & Other Personal Property Market Value 1. $ 2. $ 3, $ 4. $ 5. $ 6. $ TOTAL CARS & OTHER PERSONAL PROPERTY $ ________________ CV-AFF5 Pursuant to Local Court Rule 11.02 revised 4/1/08 Page 5 of 7 American LegalNet, Inc. www.FormsWorkFlow.com Businesses: 1. Business Interest 2. 3. 4. 5. 6. TOTAL BUSINESS Financial Assets (Cash or Cash Equivalents)