Personal History and Financial Affidavit Page 1 APPENDIX A IN THE COMMON PLEAS COURT OF HANCOCK COUNTY, OHIO DOMESTIC RELATIONS DIVISION Case No.: Plaintiff/Petitioner VS. PERSONAL HISTORY AND FINANCIAL AFFIDAVIT Defendant/Petitioner / NOTICE: This Personal History and Financial Affidavit must be completed and filed with Court at the time of the filing of the Complaint or an Answer. You have a duty to ascertain answers to all questions and to update this information as required by Local Rule or Court Order. If there is no way for the requested information to be obtained and provided, insert 223unknown224 in the blank. If you do not have any property or debt in a listed category, put "None" in the blank. DO NOT LEAVE BLANKS AFTER ANY QUESTION, AND PLEASE INCLUDE INFORMATION ABOUT YOUR SPOUSE, TO THE EXTENT KNOWN. STATE OF ) ) Sworn and Subscribed (SS): COUNTY OF ) I, (Printed Name of Affiant), being first duly sworn, do swear and affirm that I am the Plaintiff/Petitioner/Defendant in this matter and that all of the information contained herein is true and accurate to the best of my knowledge and belief and that I have or will provide supporting documentation of the information included in this Affidavit. DO NOT ATTACH SUPPORTING DOCUMENTS TO THIS AFFIDAVIT, BUT YOU MAY BE REQUIRED TO PRODUCE THEM LATER. HUSBAND WIFE Name Current Mailing Address Residence Address (if different from mailing address) Date of Birth American LegalNet, Inc. www.FormsWorkFlow.com Personal History and Financial Affidavit Page 2 HUSBAND WIFE EDUCATION High School College Grad School Other Indicate number of years completed High School College Grad School Other EMPLOYMENT (the following information should be provided for each employer) Current Employer Address and Phone Number of Employer Position Held/Title Supervisor 12 24 26 52 Other Scheduled Paychecks per year 12 24 26 52 Other $ Current Monthly Gross Income $ $ Annual Gross Income (based on prior or current year's earnings) $ $ Gross Bonuses/Overtime year-to-date $ $ Anticipated Gross Bonuses/Overtime for current year $ $ Gross Bonuses/Overtime for last year $ $ Gross Bonuses/Overtime for year before last $ Other Sources of Monthly Income $ Public Assistance $ $ Food Stamps $ $ Social Security $ $ S.S.I. $ $ Disability $ $ Unemployment $ $ Worker222s Compensation $ $ Veteran222s Benefits $ $ Armed Forces Allotment $ $ Child Support Received $ American LegalNet, Inc. www.FormsWorkFlow.com Personal History and Financial Affidavit Page 3 HUSBAND WIFE $ Spousal Support Received $ $ Rental Income $ $ Interest $ $ Trust Income $ $ Dividends $ $ Other (source of Other income) $ $ Prior Year tax refunds $ Monthly Deductions from Paycheck $ Court Ordered Child Support (Court and Case Number) $ $ Court Ordered Spousal Support (Court and Case Number) $ $ City Income Tax $ $ Social Security/Public Pension $ $ Union Dues $ $ Charity $ $ Pension/401K/IRA/etc. $ $ Savings $ $ Medical Insurance $ $ Other $ SELF-EMPLOYED INCOME Name of Business Type/Nature of Business Address In Business Since $ Gross Receipts year-to-date $ $ Gross Receipts last year $ American LegalNet, Inc. www.FormsWorkFlow.com Personal History and Financial Affidavit Page 4 CHILDREN (of this marriage) Name Sex DOB Age Grade Currently Residing With 1. 2. 3. 4. 5. If any of the children are born prior to the date of your marriage, is there any issue regarding paternity? Yes No HUSBAND222S CHILDREN (not of this marriage) Name Sex DOB Is Husband Custodian? Does Husband Pay Support? 1. Yes No Yes No 2. Yes No Yes No 3. Yes No Yes No 4. Yes No Yes No 5. Yes No Yes No WIFE222S CHILDREN (not of this marriage) Name Sex DOB Is Wife Custodian? Does Wife Pay Support? 1. Yes No Yes No 2. Yes No Yes No 3. Yes No Yes No 4. Yes No Yes No 5. Yes No Yes No HEALTH INSURANCE (for minor children of this marriage) Is there currently health insurance covering the child(ren) of this marriage? Yes No If so, who is providing the coverage for the children? Husband Wife Both If you are not currently providing health insurance for the child(ren) of this marriage, is it available to you? Yes No Annual cost to provide health insurance for the minor child(ren): $ (The difference between the cost to insure the employee and the family) Is there an insurance card or form that is necessary to obtain services? Yes No Is there prescription coverage? Yes No Is there an Rx card? Yes No Who has these cards? Husband Wife Both Are there certain service providers that the plan requires you to use? Yes No Coverage in network: 100/0 90/10 80/20 70/30 other Coverage out of network: 100/0 90/10 80/20 70/30 Other American LegalNet, Inc. www.FormsWorkFlow.com Personal History and Financial Affidavit Page 5 CURRENT MARRIAGE Date of Marriage: Currently living together? Yes No If no, date of separation: Place of Marriage (City/State): Number of this marriage: Husband: Wife: Have there been actions previously filed to dissolve or otherwise terminate this marriage? Yes No If so, where: when: case no.: disposition: ASSETS OF PARTIES (Indicate owner: H - husband, W - wife, J - jointly owned) (attach extra forms as necessary) CHECKING / SAVINGS / CDs / CASH Owner Acct. No. (last 4 #222s) and Type Location Current Balance Existed Prior to Marriage Yes / No Yes / No Yes / No Yes / No Yes / No REAL PROPERTY (list residence first) Owner Location/Address Estimated Value Amount Owed Owned Prior to Marriage Yes / No Yes / No Yes / No Yes / No MOTOR VEHICLE, MOTORCYCLES, BOATS, MOBILE HOMES, CAMPERS, etc. (Include untitled vehicles) Owner Make/Model/Description Estimated Value Amount Owed Lender Owned Prior to Marriage Yes / No Yes / No Yes / No Yes / No Yes / No American LegalNet, Inc. www.FormsWorkFlow.com Personal History and Financial Affidavit Page 6 STOCKS, BONDS, SAVINGS BONDS, MUTUAL FUNDS, etc. Owner Number of Shares Company Current Value Owned Prior to Marriage Yes / No Yes / No Yes / No Yes / No Yes / No LIFE INSURANCE Owner Company Policy Number Face Value Cash Value Owned Prior to Marriage Yes / No Yes / No Yes / No Yes / No Yes / No PENSION BENEFITS, RETIREMENT FUNDS, IRAs, 401(K)s, etc. Owner Vested Type of Plan Company Current Value Loan?(balance) Owned Prior to Marriage Yes/No Yes / No Yes/No Yes / No Yes/No Yes / No Yes/No Yes / No Yes/No Yes / No CLOSELY HELD BUSINESS / SOLE PROPRIETORSHIP / CORPORATION / PARTNERSHIP / etc. Owner Name of Business Type/Form % Ownership Estimated Value Owned Prior to Marriage Yes / No Yes / No Yes / No Yes / No Yes / No INCOME TAX OR OTHER REFUNDS DUE PARTIES Federal: $ State: $ Other: $ American LegalNet, Inc. www.FormsWorkFlow.com Personal History and Financial Affidavit Page 7 OTHER ASSETS (hobby equipment, antiques, guns, riding mowers, farm equipment, sporting equipment, cemetery lots, loans due the parties, etc.) Additional sheets as necessary Item Description Value Item Description Value $ $ $ $ $ $ $ $ $ $ $ $ $ $ HOUSEHOLD GOODS / PERSONAL PROPERTY Attach an itemized list of all property that is or may be in dispute and for each state the following: description, current location, and whether it was owned prior to the marriage. DEBTS/LIABILITIES OF THE PARTIES (Indicate party obligated: H - husband, W - wife, J - jointly obligated) (attach extra forms as necessary) REAL ESTATE MORTGAGES / LAND CONTRACTS Debtor To whom owed Property related to debt Monthly Payment Balance Due $ $ $ $ $ $ $ $ $ $ MOTOR VEHICLES, etc. Debtor To whom owed Property related to debt Monthly Payment Balance Due $ $ $ $ $ $ $ $ $ $ OTHER LOANS / HOUSEHOLD FINANCE LOANS / etc. Debtor To whom owed Property related to debt Monthly Payment Balance Due $ $ $ $ $ $ $ $ $ $ American LegalNet, Inc. www.FormsWorkFlow.com Personal History and Financial Affidavit Page 8 CREDIT CARD ACCOUNTS Debtor To whom owed Account Number (last 4 #222s) Minimum Monthly Payment Balance Due $ $ $ $ $ $ $ $ $ $ $ $ $ $ OTHER DEBTS Debtor To whom owed Description of Obligation Minimum Monthly Payment Balance Due $ $ $ $ $ $ $ $ $ $ $ $ MONTHLY LIVING EXPENSES This form shows: Current expenses for spouse and myself based upon a single household Current expenses for myself in a separate household from my spouse My e