IN THE CIRCUIT COURT OF THE 22ND JUDICIAL CIRCUIT McHENRY COUNTY, ILLINOIS IN RE: The  Marriage of:  Custody of: _________________________________ Petitioner and _________________________________ Respondent  ) ) ) ) ) ) ) ) Support of: 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: __________________________________ Telephone No: ( ______ ) _______________________ Address: ________________________________ Petitioner Date of Birth ________________(mmddyyyy) _________________________________________ Respondent Date of Birth _______________(mmddyyyy) Date of Marriage: _________________________ Date of Dissolution of Marriage (if applicable) __________________ (mmddyyyy) (mmddyyyy) Minor and/or Dependent Children of this Marriage: NAME Date of Birth Currently Living With (mmddyyyy) (Attach additional page(s) as needed) Current Employer: Self Employment: Other Employment  Check if unemployed Address: Address: Address: Number of Paychecks per year: (Please Check Box)  12  24  26  52  Other_________ CV-AFF5 Pursuant to Local Court Rule 11.02 revised 1/1/08 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 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 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 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 MONTHLY PAYMENT $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ ____________________ (Attach additional page(s) as needed) 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 $ $ $ $ $ ___________________ Cars & Other Personal Property Market Value 1. $ 2. $ 3, $ 4. $ 5. $ 6. $ TOTAL CARS & OTHER PERSONAL PROPERTY $ ________________ Debt $ $ $ $ $ $ $ ___________________ CV-AFF5 Pursuant to Local Court Rule 11.02 Page 5 of 7 American LegalNet, Inc. www.FormsWorkflow.com Businesses: 1. Business Interest 2. 3. 4. 5. 6. Market Value $ $ $ $ $ $ $ _________________ TOTAL BUSINESS Financial Assets (Cash or Cash Equivalents): 1. Savings or interest-bearing accounts 2. Checking Accounts 3. Certificates of Deposit 4. Money Market Accounts 5. Cash 6, Other (specify): 7. Other (specify) TOTAL CASH OR CASH EQUIVALENTS Retirement & Deferred Compensation: 1. Retirement 2. 3. 4. TOTAL RETIREMENT & DEFERRED COMPENSATION Investment Accounts and Securities: 1. Stocks 2. Bonds 3. Tax exempt securities 4. Other (specify): 5. Other (specify): 6, Other (specify): TOTAL INVESTMENT ACCOUNTS & SECURITIES Debt $ $ $ $ $ $ $ ___________________ Market Value $ $ $ $ $ $ $ $ _____________________ $ _________________ Market Value $ $ $ $ $ _____________________ $ _________________ Market Value $ $ $ $ $ $ $ _____________________ $__________________ RECAP OF INCOME AND EXPENSES: Net Monthly Income (+) Total Monthly Living Expenses (-) Less Monthly Debt Service (-) Total Income Available per Month (=) $ ___________________ $ ___________________ $ ___________________ $ ___________________ CV-AFF5 Pursuant to Local Court Rule 11.02 Page 6 of 7 American LegalNet, Inc. www.FormsWorkflow.com STATEMENT OF HEALTH INSURANCE COVERAGE Currently effective health insurance coverage?  Yes  No Name of insurance carrier: _________________________________________________________________ Policy of Group No.: ______________________________________________________________________ Type of insurance:  Medical  Dental  Optical Deductible: Per individual: $ _________________ Per family: Persons covered:  Self  Spouse  Dependents Type of policy:  HMO  PPO  Full indemnity Provided by:  Employer Monthly costs:  Paid by Employer $___________________  Private Policy   Other Group Paid by employee: $ _____________ for dependents $ _____________ for self VERIFICATION The foregoing Financial Affidavit has been carefully read by the undersigned who states under oath, under penalties as provided by law pursuant to 735 ILCS 5/109, that this affidavit includes all of his/her income and expenses, he/she has knowledge of the matters stated and 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 certified as aforesaid that he/she believes same to be true. ________________________________________ _______________________________________ Signature of Petitioner Signature of Respondent ________________________________________ _______________________________________ Typed or Printed Name of Petitioner Typed or Printed Name of Respondent Date signed: _____________________________ Date signed: ____________________________ CV-AFF5 Pursuant to Local Court Rule 11.02 Page 7 of 7 American LegalNet, Inc. www.FormsWorkflow.com