IN THE CIRCUIT COURT OF THE NINTH JUDICIAL CIRCUIT COUNTY, ILLINOIS Petitioner, Case No: vs. Respondent. FINANCIAL AFFIDAVIT (Family Cases) (Local Court Rule G-5.1) I, contained herein is true and correct as of , having been duly sworn, upon oath, state that the information , 20 . Age: 1. My Name: Address: Occupation: D/O/B: Education: Age: 2. Opposing party: Address: Employer: Occupation: D/O/B: Education: Job Title: 3. (If Applicable): a. Date of Marriage: c. Date final Judgment of Diss. entered: b. Date of Separation: 4. My Employment Information [ ] Current Employer: Address: Address: [ ] Self Employed as: Address: [ ] Other Employment: Per [ ] Unemployed [ ] Unemployment Compensation $ Do you expect your employment to change significantly in the next 6 months? [ ] No [ ] Yes Why? Number of Paychecks per year: (Please Check box) [ ] 12 [ ] 24 [ ] 26 [ ] 52 Number of Dependents claimed on Federal Income Tax returns: [ ] Other: 5. Any Prior Support Orders (if applicable): [ ] Paid by me [ ] Paid to me. [ ] Child Support [ ] Maintenance [ ] Unallocated child support & maintenance [ ] College expenses Amount of Prior Order: $ Date of Prior Order: 6. Minor and/or dependent Children born to myself and opposing party: Name Age Date of Birth Currently Living with: (Attach additional page(s) as needed) Page 1 of 8 American LegalNet, Inc. www.FormsWorkFlow.com 7. I have additional persons dependent on me: Name Age Date of Birth Relationship 8. State Total Number of People in your Household: List Name of all Persons in your Household (exclude yourself): Name Age Date of Birth Relationship (Attach additional page(s) as needed) (Attach additional page(s) as needed) 9. Proof of Income: Pursuant to Local Court Rule G-5.1.B. [ ] I have attached or [ ] I shall have available at any hearing regarding child support, maintenance, college expenses, or disposition of property, copies of my prior year's Federal Income Tax return, including all W-2 forms and 1099 forms, and my most recent pay stub showing year to date earnings and deductions therefrom, or if the same is not provided by my employer, my five (5) most recent payroll stubs. 10. STATE AND FEDERAL INCOME TAX REFUNDS How much was your last State Income Tax Refund? $ How much was your last Federal Income Tax Refund? $ . For what tax year? . For what tax year? 11. STATEMENT OF INCOME 11a. Total Gross Monthly Earned Income Gross Salary/Wages/Base Pay Overtime/Commission Bonus Draw 11a. TOTAL GROSS MONTHLY EARNED INCOME: 11b. Total Required Monthly Deductions From Earned Income Federal Tax (based on exemptions) exemptions) State Tax (based on FICA (or Social Security equivalent: RR, Tier I) Medicare Mandatory 401(K) or retirement contributions ) Union Dues (Name of Union: Health - Medical Insurance Premiums deducted from paycheck: Myself My Dependents Prior Orders of Child Support or Mainatenance actually paid $ pursuant to Court Order No. $ Other (specify): $ Other (specify): 11b. TOTAL REQUIRED MONTHLY DEDUCTIONS FROM EARNED INCOME: 11c. TOTAL NET MONTHLY EARNED INCOME (11a. minus 11.b) 11d. TOTAL OTHER MONTHLY INCOME Social Security $ $ $ $ $ 0.00 $ $ $ $ $ $ $ $ $ $ 0.00 ($ 0.00 ) $ Page 2 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Unemployment benefits Worker's Compensation /Disability payment Public Aid/Food Stamps Pension and Retirement Benefits Interest income/Dividend income Trust income Rental income Business income (including nontaxable distributions) Partnership income [ ] Other: 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 or another 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 or another case [ ] Other: 11d. TOTAL OTHER MONTHLY INCOME $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 11. TOTAL MONTHLY NET EARNED INCOME & OTHER INCOME 0.00 $ 0.00 (Add lines 11c. and 11d.) 12. STATEMENT OF MONTHLY LIVING EXPENSES (Mark with A*@ if projected expenses. Be prepared to offer testimony in support of estimates) 12a. Household Expenses a. Mortgage or Rent (specify): $ b. Home Equity Loan payment $ c. Real Estate Taxes, Assessments (if not in mortgage) $ d. Homeowners or Renters Insurance (if not in mortgage) $ e. Condo Maintenance Fee $ f. Heat/Fuel $ g. Electricity $ h. Water $ i. Sewer $ j. Groceries and Household Supplies $ k. Garbage and Refuse Removal $ l. Home Telephone (including long distance) $ m. Cell Phone $ n. Laundry B Dry Cleaning $ o. Household help B Cleaning Services B Maid $ p. Furniture, Appliance Repair/Replacement $ q. Lawn B Garden Care / Snow removal $ r. Tobacco, Liquor, Beer, Wine, etc. $ s. Cable or Satellite Television $ t. Internet Computer Service $ $ u. Other (specify): 0.00 SUBTOTAL HOUSEHOLD EXPENSES: $ Page 3 of 8 American LegalNet, Inc. www.FormsWorkFlow.com 12b. Transportation a. Vehicle Payments (Vehicle 1) b. Vehicle Payments (Vehicle 2) c. Fuel & Oil d. License & Resgistration e. Repairs & maintenance f. Vehicle Insurance g. Other (specify): h. Other (specify): SUBTOTAL TRANSPORTATION EXPENSES: 12c. Personal Expenses (actually paid for you and dependents) a. Clothing & Shoes b. Business / Work Uniforms c. Eyeglasses / Contacts (after insurance) d. Grooming / Cosmetics e. Hairdresser / Barber f. Medical (after insurance proceeds/reimbursement) Doctor Dentist Optical Medication g. Insurance (not deducted from paycheck) Life Insurance Medical/Hospitalization Dental/Optical h. Educational Expense i. Books, magazines, newspapers, etc. j. Recreation, sports and hobby expenses k. Religious / charitable contributions l. Vacations m. Social / Club Dues n. Gifts and presents other than to children o. Other (specify): SUBTOTAL PERSONAL EXPENSES: 12d. Expenses of Minor or Dependent Children a. Education Tuition Books/Fees Lunches Transportation b. Allowance c. Child care / After-school care d. Sitters e. Child Clubs/Summer Camps f. Entertainment g. Gifts (for Holidays, birthdays, etc) h. Other (specify): SUBTOTAL CHILDREN'S EXPENSES: $ $ $ $ $ $ $ $ $ 0.00 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 0.00 $ $ $ $ $ $ $ $ $ $ $ 0.00 $ $ 12.TOTAL MONTHLY LIVING EXPENSES: 0.00 Page 4 of 8 American LegalNet, Inc. www.FormsWorkFlow.com 13. STATEMENT OF MONTHLY MARITAL DEBT PAYMENT NOT OTHERWISE LISTED Creditor's Name Payment for Balance Due Monthly Payment $ $ $ $ $ $ $ $ $ $ $ $ $ $ 0.00 $ TOTAL DEBT TOTAL MONTHLY MARITAL DEBT PAYMENT $ (Attach additional page(s) as needed) 14. STATEMENT OF MONTHLY NON-MARITAL DEBT PAYMENT NOT OTHERWISE LISTED Creditor's Name Payment for Balance Due Monthly Payment $ $ $ $ $ $ $ $ $ $ $ $ 0.00 TOTAL DEBT $ 0.00 TOTAL MONTHLY NON-MARITAL DEBT PAYMENT $ (Attach additional page(s) as needed) 15. STATEMENT OF MARITAL ASSETS Valuation Date: Market Value 15a. Marital Residence and Other Real Estate: 1. Residence at: 2. 3. Subtotal Marital Real Estate $ $ $ $ 0.00 Market Value 15b. Marital Vehicles & Other Personal Property: 1. 2. 3. 4. Subtotal Cars & Other Personal Property $ $ $ $ 15c. Marital Businesses: 1. Business Interest: 2. Subtotal Marital Businesses $ $ $ 0.00 Market Value $ 15e. Marital Financial Assets (Cash Equivalents): 1. Savings or Checking Accounts 2. Certificates of Deposit 3. Other (specify): 4. Other (specify): Subtotal Marital Cash Equivalents: 15f. Marital Retirement & Deferred Compensation: 1. Retirement: 2. Subtotal Marital Retirement & Deferred Comp. 0.00 Market Value $ $ $ $ $ 0.00 Market Value $ $ $ Page 5 of 8 0.00 American LegalNet, Inc. www.FormsWorkFlow.com 15g. Marital Investment Accounts and Securities: $ 1. Stocks/Bonds 2. Tax exempt securities 3. Other (specify): Subtotal Marital Investment Accounts and Securities Market Value $ $ $ 0.00 15.TOTAL ALL MARITAL ASSETS $ 0.00 16. STATEMENT OF NON-MARITAL ASSETS and DEBTS Valuation Date Market Value 16a. Non-Marital Residence and Other Real Estate: $ $ 1. Non-Marital Residence at: 2. Subtotal Non-marital Real Estate $ 16b. Non-Marital Vehicles & Other Personal Property: $ 1. $ 2. Subtotal Non-marital Personal Property Market Value $ 0.00 Market Value 16c. Non-Marital Businesses: 1. Business Interest: 2. Subtotal Non-marital Businesses Debt $ $ $ $ $ Market Value 16c. Non-Marital Financial Assets (Cash or Equivalents): 1. Savings or Checking Accounts 2. Certificates of Deposit 4. Other (specify): Subtotal Non-marital Fin. Assets $ $ $ $ 0.00 Market Value 16d. Non-Marital Retirement & Deferred Compensation: $ 1. Retirement: $ 2. Subtotal N.M. Retirement & Deferred Compensation 16e. Non-Marital Investment Accounts and Securities: 1. Stocks 2. Bonds 3. Other (specify): Subtotal N.M. Investment Accounts and Securities 0.00 $ 0.00 Market Value $ $ $ $ 16. TOTAL ALL NON-MARITAL ASSETS AND DEBTS 0.00 $ 0.00 Page 6 of 8 American LegalNet, Inc. www.FormsWorkFlow.com 17. STATEMENT OF HEALTH INSURANCE COVERAGE CURRENTLY IN EFFECT Name of insurance carrier: Policy or Group No.: Type of insurance: [ ] Medical [ ] Dental [ ] Optical Persons covered: [ ] Self [ ] Spouse [ ] Dependents Per family: $ Deductible: Per individual: $ Type of policy: [ ] HMO [ ] PPO [ ] Full indemnity Provided by: [ ] Employer [ ] Private Policy [ ] Other Group Monthly costs: [ ] Paid by Employer and/or [ ] Paid by employee for self $ [ ] Paid by employee for dependents $ VERIFICATION The foregoing Financial Affidavit has been carefully read by the undersigned who states under oath and under penalties of perjury as provided by law pursuant to 735 ILCS 5/109, that this Financial Affidavit includes all of his/her income and expenses, that he/she has knowledge of the matters stated, and that he/she certifies that the statements set forth in this Affidavit are true and correct, except as to matters specifically stated to be on information and belief, and as to such matters the undersigned certifies as aforesaid that he/she verily believes same to be true. Date Signed: Signature of Affiant Prepared by: [ ] Self [ ] Attorney's Name: Address: City Phone Fax ARDC# Typed or Printed Name of Affiant State Zip NOTICE: Court Filing Instructions and Proof of Income: Do not file this Financial Affidavit with the Clerk of the Court. Pursuant to Local Court Rule G-5.1, a copy of this completed and signed Financial Affidavit must be served by the moving party on all parties entitled to notice not less than seven (7) days before the date of hearing on a pleading seeking to establish, modify, or otherwise affect issues of support or maintenance, disposition of property, college expenses or attorney's fees, whether temporary or permanent in nature, and by the responding party not less than two (2) days before said hearing date the case. If such an affidavit has been served for purposes of a hearing, an additional affidavit need not be served for subsequent hearings unless there has been a change in financial circumstances. Pursuant to Local Court Rule G-5.1, each party shall file with the Clerk of the Circuit Court within seven (7) days after service of this Financial Affidavit a Certificate of Compliance and Service, certifying this Financial Affidavit has been completed and further setting forth the date on which this completed Financial Affidavit was served upon the opposing party. This Financial Affidavit shall not be filed with the Clerk of the Circuit Court. Both parties shall, however, be required to provide a copy of the Financial Affidavit, together with a copy of the notice, motion and any points and authorities relied upon, to the judge before whom the motion is set or assigned. The judge's copy so provided for the judge pursuant to Local Rule shall not be filed as part of the court record. Pursuant to Local Court Rule G-5.1.B, each party shall also have available at any such hearing copies of the prior year's Federal Income Tax return, including all W2 forms and 1099 forms, and the most recent pay stub showing year to date earnings and deductions therefrom, or if the same is not provided by their employer, their five (5) most recent payroll stubs. Failure to comply with these Rules may result in sanctions pursuant to local and Supreme Court Rule. Page 7 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Page 8 of 8 American LegalNet, Inc. www.FormsWorkFlow.com