STATE OF ILLINOIS ) ) SS COUNTY OF WILL ) IN THE CIRCUIT COURT OF THE TWELFTH JUDICIAL CIRCUIT WILL COUNTY, ILLINOIS IN RE THE MARRIAGE OF: _____________________________________________ Plaintiff VS. CASE NO.__________________________ _____________________________________________ Defendant INCOME/EXPENSE AFFIDAVIT _______________________________________________________, on oath, states: 1. The parties have been married______________years; my age is ____________years. 2. There are________children of the marriage, aged____________________________________. 3. I (am) 4. My customary monthly living expenses are: Rent/Mortgage(s) $______________________ House Insurance $______________________ Tax Escrow $______________________ Food (for _________People) $______________________ Doctors/Dentists $______________________ Prescriptions $______________________ Lien Payment on Auto $______________________ Gas, Oil, Maintenance $______________________ Auto Insurance/Month $______________________ Utilities: Gas $______________________ Electric $______________________ Water and Garbage $______________________ Telephone $______________________ Cable $______________________ Life Insurance $______________________ Clothes (for_____People) $______________________ Grooming (Personal) $______________________ Children School: Tuition $______________________ Books $______________________ Lunch Program $______________________ Babysitter $______________________ Clubs/Entertainment $______________________ Gifts/Donations $______________________ Vacations $______________________ Children’s Activities $______________________ Miscellaneous: ________________________ $______________________ ________________________ $______________________ (am not) residing in the marital residence. TOTAL FIXED MONTHLY EXPENSES TOTAL MINIMUM CREDIT BILL PAYMENTS TOTAL EXPENSES $______________________ $______________________ $______________________ 2000 © American LegalNet, Inc. 5. MY TOTAL GROSS INCOME last calendar year was $________________________ MY FEDERAL TAX REFUND last calendar year was $_________________________ 6. My employer is__________________________________________________________ I earn $______________ per hour and work ____________hours per pay period; my pay period is (Weekly) (Biweekly) (Semi-Monthly) (Monthly) NUMBER OF EXEMPTIONS I CLAIM IS:_______________ Gross Income Monthly Less: Federal Withholding State Withholding FICA Union Dues Mandatory Retirement Mandatory Hospital Insurance Court Ordered Support I Pay Other: _______________________ _______________________ $_______________ $____________ $____________ $____________ $____________ $____________ $____________ $____________ $____________ $____________ TOTAL “STATUTORY” DEDUCTIONS NET INCOME PER MONTH OTHER INCOME FROM ALL SOURCES TOTAL INCOME FROM ALL SOURCES (e.g., bonus, interest, rent, etc.) 7. $________________ $________________ $________________ $________________ ASSETS A. Real Estate _____________________________ _____________________________ _____________________________ __________________ __________________ __________________ ___________________ ___________________ ___________________ B. Vehicles _____________________________ _____________________________ _____________________________ __________________ __________________ __________________ ___________________ ___________________ ___________________ C. Bank Accounts/Investments _____________________________ _____________________________ _____________________________ _____________________________ __________________ __________________ __________________ __________________ ___________________ ___________________ ___________________ ___________________ FAIR MARKET VALUE DEBT D. Employment Benefits (Include Past and Present Employers) _____________________________ __________________ _____________________________ __________________ _____________________________ __________________ ___________________ ___________________ ___________________ E. Other Assets (of any description whatsoever) _____________________________ __________________ _____________________________ __________________ _____________________________ __________________ ___________________ ___________________ ___________________ 2000 © American LegalNet, Inc. 8 LIABILITIES 1. BALANCE PAYMENT Mortgages __________________________ __________________________ __________________________ ____________________ ____________________ ____________________ ________________ ________________ ________________ ___________________ ___________________ ___________________ ________________ ________________ ________________ _________________________ _________________________ _________________________ ___________________ ___________________ ___________________ ________________ ________________ ________________ Unpaid Medical Bills _________________________ _________________________ _________________________ ___________________ ___________________ ___________________ ________________ ________________ ________________ ___________________ ___________________ ___________________ ________________ ________________ ________________ ___________________ ___________________ ___________________ ________________ ________________ ________________ 2. Auto Loans _________________________ _________________________ _________________________ 3. Credit Accounts 4. E. Other Loans _________________________ _________________________ _________________________ F. Educational Loans _________________________ _________________________ _________________________ Under penalties of perjury, provided by law in section 1-109 of the Code of Civil Procedure, I certify that the information in this Affidavit is true, correct and complete. Date:___________________________ _________________________________ 2000 © American LegalNet, Inc.