Post Decree Or Parentage Financial Affidavit Of

IN THE COMMOM PLEAS COURT OF SUMMIT COUNTY, OHIO DIVISION OF DOMESTIC RELATIONS _____________________________________ Plaintiff / Petitioner (1) Address: ______________________________ ______________________________ Phone: _______________________ Attorney CASE NO. _______________________ MOTION NO. _______________________ SETS NO. JUDGE _______________________ _______________________ ____________________________ ___________________________ MAGISTRATE _______________________ Attorney Address Attorney telephone ___________________________________ V. _____________________________________ Defendant / Petitioner (2) / Respondent Address: ______________________________ ______________________________ Phone: _______________________ Post Decree or Parentage Financial Affidavit of ___________________________ (Your Name) Date of Prior Decree ____________________________ Attorney Address ___________________________ Attorney Attorney telephone ___________________________________ Notes: In accordance with Local Rules 2.02(B) & 2.07 of this court, this affidavit must be filed by each party with every postdecree motion or parentage case that concerns support. You will be required to provide proof of income per local rule and O.R.C. 3119.05. You are under a continuing legal duty to file an updated version of this form if you learn of any additional information. If more space is needed, attach additional page(s). I. Information Required for Support Calculation: A. Minor or Dependent Children in This Case (Include adopted children and any child of the parties who is over 18 and handicapped) Child's Name Date of Birth Male / Female Age Residing with Initialed Financial Disclosure Affidavit Page 1 American LegalNet, Inc. www.FormsWorkflow.com B. Other Minor Children Living in My Household Child's Name Date of Birth Male / Female Age Relationship C. Other Minor Children of Mine, Not Living in My Household Child's Name Date of Birth Male / Female Age Residing with II. Child Support Guideline Adjustment: Father (All Figures Per Year) Court ordered child support you pay for other child(ren) in another case Case Number where support ordered Date of initial order Court ordered spousal support you pay to a former spouse Number of your other dependent children living with you from a different marriage or relationship Is the other parent of any of your other children also in your household? If yes, how many children do you have with the parent who lives with you? Court ordered child support you receive for the dependent child(ren) you indicated on line above (other parent not in home) Child care expenses you pay for child(ren) of this case (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.) $ or % $ or % Yes No Yes No Mother (All Figures Per Year) Private health insurance cost to you for children (family plan cost less individual plan cost) Total number of dependents covered by your insurance Current partner's gross income Initialed Financial Disclosure Affidavit Page 2 American LegalNet, Inc. www.FormsWorkflow.com III. Income [As defined in O.R.C. 3119.01(C)]: A. Gross Yearly Income from Employment Father Gross yearly employment income Employer Payroll Address City, State, Zip Number of paychecks per year Year-to-date Gross Income 12 24 26 52 (If not known, please estimate. Put "EST" after each estimated figure.) Mother Gross yearly employment income Employer Payroll Address City, State, Zip Check the number of Paychecks per year 12 24 26 52 Through date of Year-to-date Gross Income Prior Year's Tax Refund Through date of Prior Year's Tax Refund B. Annual Overtime, Commissions, Bonuses Father Year 3 is Most Recent Year _____ Year 1 _____ Year 2 _____ Year 3 Y-T-D This Year Through: Base Income Overtime, commission, Bonuses (If not known, please estimate. Put "EST" after each estimated figure.) Mother Year 3 is Most Recent Year _____ Year 1 _____ Year 2 _____ Year 3 Y-T-D This Year Through: Base Income Overtime, commission, Bonuses D. Gross Self-Employment Income (If not known, please estimate. Put "EST" after each estimated figure.) Use Gross Annual Figures for Most Recent Full Year. See O.R.C. 3119.01(C) Father Business Receipts Ordinary & Necessary Business Expenses Net Business Income Business Receipts Ordinary & Necessary Business Expenses Net Business Income Mother D. Other Income All other income, actual or expected, including pension, social security, workers compensation, commissions, royalties, disability benefits, trust income, annuities, reoccurring capital gains, unemployment benefits, rents, expense-sharing, dividends, interest, AFDC, SSI, food stamps, spousal support received from a prior spouse, etc. (If not known, please estimate. Put "EST" after each estimated figure.) Father Describe Per Year Describe Mother Per Year Initialed Financial Disclosure Affidavit Page 3 American LegalNet, Inc. www.FormsWorkflow.com E. Total Annual Income Father Total gross annual income Total average gross monthly income Average monthly deductions Total net monthly income ÷ 12 = Less Total gross annual income Total average gross monthly income Average monthly deductions Total net monthly income ÷ 12 = Less Mother = = F. Benefits of Employment (Use of company car, country club memberships, stock options, etc.) Father Benefits Values Benefits Mother Values IV. Private Health Insurance Information CHECK ALL APPLICABLE BOXES AND FILL-IN ALL BLANKS. My child(ren is/are covered by low-income government ­assisted health care coverage (Healthy Start/Medicaid, etc.) LIST OF PLANS I have the following private health insurance policies, contracts or plans to cover the child(ren) available to me. Name of policy, contract or plan _______________________________ _______________________________ _______________________________ _______________________________ Name of Insurance Company _________________________________ _________________________________ _________________________________ _________________________________ Entity/group through which policy, contract or plan is available _________________________________ _________________________________ _________________________________ _________________________________ Initialed Financial Disclosure Affidavit Page 4 American LegalNet, Inc. www.FormsWorkflow.com NO PRIVATE HEALTH INSURANCE I DO NOT HAVE the child(ren) enrolled in private health insurance because: health insurance is not available