Page 1 of 4 Office of Dispute Resolution SEVENTH JUDICIAL ADMINISTRATIVE DISTRICT P.O. BOX 963 CARTERSVILLE, GA 30120 www.7jad.com PHONE: (770) 387-4820 TOLL FREE: (877) 655-6865 FAX: (770) 387-5479 IN THE SUPERIOR COURT OF ___________COUNTY STATE OF GEORGIA ____________________, Plaintiff, Vs. ____________________, Defendant, * * * * * * * * * Civil Action File No.__________________ DOMESTIC RELATIONS FINANCIAL AFFIDAVIT 1. Affiant's Name ________________________________ Age: _____________ Affiant's Social Security No. __________________________________________ Spouse's Name: _______________________________ Age:______________ Date of Marriage: _________________ Date of Separation: ______________ Names and birthdates of children of this marriage: Name Date of Birth Resides With _____________________ _____________________ _________________ _________________ ___________________ ___________________ Names and birthdates of children of prior marriage(s) residing with Affiant: Name Date of Birth Resides With _____________________ 2. _________________ ___________________ $____________________ $____________________ $____________________ +____________________ $____________________ $____________________ $____________________ American LegalNet, Inc. www.FormsWorkFlow.com SUMMARY OF AFFIANT'S INCOME AND NEEDS (a) Gross monthly income (from Item 3A) (b) Net monthly income (from Item 3C) (c) Average monthly expenses (Item 5A) Monthly payments to creditors (Item 5B) Total monthly expenses and payments To creditors (Item 5C) (d) Amount of spousal / child support needed by Affiant (e) Amount of child support indicated by Child Support Guidelines Page 2 of 4 3. A. Affiant's Gross Monthly Income: (All income must be entered based on monthly average regardless of date of receipt. Where applicable, income should be annualized). Salary Bonuses, commissions, allowances, overtime, tips and Similar payments (based on past 12 month average or Time of employment if less that a year). ATTACH SHEETS ITEMIZING THIS INCOME, $____________________ ____________________ Business income from sources such as self employment, Partnership, close corporations, and/or independent Contracts (gross receipts minus ordinary and necessary Expenses required to produce income), ATTACH SHEET ITEMIZING THIS INCOME. _____________________ Disability / unemployment, / worker's comp Pension, retirements or annuity payments Other public benefits (specify) Social Security benefits Spousal or child support from prior marriage Interest and dividends Rental income (gross receipts minus ordinary and Necessary expenses required to produce income) ATTACH SHEET ITEMIZING THIS INCOME Income from royalties, trusts or estate Gains derived from dealing in property (not including Non-recurring gains). Other income of a recurring nature (specify source) GROSS MONTHLY INCOME _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ $_ _ _ _ _ _ _ _ _ _ _ _ _ _ B. List and describe all benefits of employment, e.g., automobile and/or auto allowance, insurance (auto, life, disability, etc), deferred compensation, employer contribution to retirement or stock, club memberships, and reimbursed expenses (to the extent they reduce personal living expenses). ATTACH SHEET, IF NECESSARY. ____________________________________________________________________ C. Net monthly income from employment: (deducting only State and federal taxes and FICA) $_ _ _ _ _ _ _ _ _ _ _ _ _ _ Affiant's pay period (i.e., weekly, monthly, etc.): ______________________ Number of exemptions claimed: ______________________ 4. Assets (if you claim or agree that all or part of an asset in non-marital, indicate the non-marital portion under the appropriate spouse's column. The total value of each asset must be listed in the "value" column. "Value" means what you feel the item of property would be worth if it were offered for sale). Description Value Separate Asset of Husband Separate Asset of Wife American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 4 Cash Stocks, bonds $_____________ $_____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ CDs/Money Mkt Accts $______________ Real Estate: Home Other Automobile Money Owed You Retirement/IRA Furniture/furnishings Jewelry Life Insurance (cash value) Collectibles Bank accounts Checking Savings Other Assets ______________ TOTAL ASSETS $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_ _ _ _ _ _ _ _ _ _____________ _____________ _____________ _____________ _________ _____________ _____________ _____________ _____________ _________ 5. A. (Indicate with (*) all which are estimates rather than actual figures than actual figures Taken from records or personal knowledge). AVERAGE MONTHLY EXPENSES HOUSEHOLD: Mortgage/Rent payments Property taxes Insurance Electricity Water Garbage/Sewer Telephone Gas Repairs/Maintenance Lawn care Pest control Cable TV Misc. Household Grocery items Meals outside of home Other (specify)_______ TOTAL HOUSEHOLD EXPENSES _______ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ AUTOMOBILE Gasoline Insurance Repairs Auto tags and license Other (specify)_____ ________ ________ ________ ________ ________ TOTAL AUTOMOBILE EXPENSES ______ CHILDREN'S EXPENSE Childcare School tuition School supplies/expenses Lunch money ________ ________ ________ ________ American LegalNet, Inc. www.FormsWorkFlow.com Page 4 of 4 Clothing Diapers Medical, dental, prescription Grooming/hygiene Gifts Entertainment Activities INSURANCE Health Life Disability Other ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ Misc. (attach sheet) Other (attach sheet) Alimony paid (to former spouse) Child support paid ________ ________ ________ ________ (to former spouse) TOTAL OTHER EXP. $________ TOTAL MONTHLY EXPENSES $_