DEKALB COUNTY SUPERIOR COURT STATE OF GEORGIA , Plaintiff, Civil Action vs. Case Number , Defendant. DOMESTIC RELATIONS FINANCIAL AFFIDAVIT (1) Your Name: Your Age: Spouse’s Name: Spouse’s Age: Date of Marriage: Date of Separation: Names and birth dates of children for whom support is to be determined in this action: Name Date of Birth Resides with Date of Birth Resides with Names and birth dates of your other children: Name (2) S UMMARY OF Y OUR I NCOME AND N EEDS: (fill out this part after you complete pages 2-5) (A) Gross Monthly Income (from Item 3A below) $ (B) Net Monthly Income (from Item 3B below) $ (C) Average Monthly Expenses (Item 5A below) $ Monthly Payments to Creditors (Item 5B below) $ Total Monthly Expenses & Payments to Creditors (Item 5C below) $ Domestic Relations Financial Affidavit - rev. DRAFT January 8, 2007 Provided by the DeKalb County Superior Court and the Atlanta Legal Aid Society Page 1 of 6 American LegalNet, Inc. www.FormsWorkflow.com (3) (A) Y OUR G ROSS M ONTHLY I NCOME: (Complete this section or attach Child Support Schedule A. All income must be entered based on monthly average regardless of date of receipt. Where applicable, income should be annualized.) Salary or Wages — ATTACH COPIES OF 2 MOST RECENT WAGE STATEMENTS $ Commissions, Fees & Tips $ Income from self-employment, partnership, close corporations and independent contracts (gross receipts minus ordinary and necessary expenses required to produce income) ATTACH SHEET ITEMIZING YOUR CALCULATIONS Rental income (gross receipts minus ordinary and necessary expenses required to produce income) ATTACH SHEET ITEMIZING YOUR CALCULATIONS $ $ Bonuses $ Overtime Payments $ Severance Pay $ Recurring Income from Pensions or Retirement Plans $ Interest and Dividends $ Trust income $ Income from Annuities $ Capital Gains $ Social Security Disability or Retirement Benefits $ Worker’s Compensation Benefits $ Unemployment Benefits $ Judgments from Personal Injury or Other Civil Cases $ Gifts (cash or other gifts that can be converted to cash) $ Prizes & Lottery Winnings $ Alimony and maintenance from persons not in this case $ Assets which are used for support of family $ Fringe Benefits (if significantly reduce living expenses) $ Any Other Income (Do not include means-tested public assistance, such as TANF or food stamps.) $ TOTAL Gross Monthly Income (also write in 2A on page one) $ (3)(B) Net Monthly Income From Employment (deducting only state and federal taxes and FICA) (also write in 2B on page one) $ Domestic Relations Financial Affidavit - rev. DRAFT January 8, 2007 Provided by the DeKalb County Superior Court and the Atlanta Legal Aid Society Page 2 of 6 American LegalNet, Inc. www.FormsWorkflow.com Your Pay Period (i.e., monthly, weekly, etc.): Number of Exemptions Claimed by You for Tax Purposes: (4) A SSETS (List all assets here, including both non-marital and marital property. If you claim or agree that all or part of an asset is non-marital, indicate the non-marital portion under the appropriate spouse’s column and state the amount and the basis: pre-marital, gift, inheritance, source of funds, etc. 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 Separate Asset of Wife Separate Asset of Husband Value Cash $ $ $ Stocks, Bonds $ $ $ CD’s / Money Market Accounts $ $ $ (1) $ $ $ (2) $ $ $ (3) $ $ $ Retirement Pensions, 401(k), IRA or Profit-Sharing $ $ $ Money Owed to You (or Spouse) $ $ $ Tax Refund Owed to You $ $ $ $ $ $ $ Basis of the Claim (pre-marital, gift, inheritance, etc.) $ Bank Accounts (list each account below): Real Estate (list properties & mortgages): Home Debt owed on Home Other Real Estate Debt owed on Other Real Estate $ $ $ Automobiles / Vehicles (list vehicles & amounts owed on each one): (1) $ Debt owed on Vehicle (1) (2) $ $ $ $ $ Debt owed on Vehicle (2) $ $ Domestic Relations Financial Affidavit - rev. DRAFT January 8, 2007 Provided by the DeKalb County Superior Court and the Atlanta Legal Aid Society Page 3 of 6 American LegalNet, Inc. www.FormsWorkflow.com (4) A SSETS (continued) Description Separate Asset of Wife Separate Asset of Husband Value Life Insurance (net cash value) $ $ $ Furniture / Furnishings $ $ $ Jewelry $ $ $ Collectibles $ $ $ Other Assets (specify): $ $ $ $ $ $ $ $ $ $ $ Basis of the Claim (pre-marital, gift, inheritance, etc.) $ TOTAL ASSETS (5)(A) A VERAGE M ONTHLY E XPENSES FOR Y OU AND Y OUR H OUSEHOLD HOUSEHOLD EXPENSES Mortgage or Rent Payments $ Gas $ Property taxes $ Repairs & Maintenance $ Homeowner’s / Renter’s Insurance $ Lawn Care $ Electricity $ Pest Control $ Water $ Cable TV / Internet Access $ Garbage & Sewer $ Misc. Household & Grocery Items $ Meals Outside Home $ Other (specify) $ Telephones Residential Lines $ Cellular Telephones $ $ AUTOMOTIVE Gasoline & Oil $ Auto Tags / Registration / License $ Repairs & Maintenance $ Insurance $ OTHER VEHICLES (boats, trailers, RVs, etc.) Gasoline & Oil $ Tags / Registration / License $ Repairs & Maintenance $ Insurance $ Domestic Relations Financial Affidavit - rev. DRAFT January 8, 2007 Provided by the DeKalb County Superior Court and the Atlanta Legal Aid Society Page 4 of 6 American LegalNet, Inc. www.FormsWorkflow.com CHILDREN’S EXPENSES Child Care (total monthly cost) $ Allowance $ School Tuition $ Children’s Clothing $ Tutoring $ Diapers $ Private lessons (e.g., music, dance) Medical, Dental, Prescriptions $ (out-of-pocket uncovered expenses) $ School Supplies / Expenses $ Grooming / Hygiene $ Lunch Money $ Gifts from children to others $ Entertainment $ Other Educational Expenses (list type & amount): Activities (including extra-curricular, ______________________ $ ______________________ $ school, religious, cultural, etc.) Summer Camps $ $ OTHER INSURANCE Health Insurance $ Children’s portion: Life Insurance $ Dental Insurance $ Relationship of Beneficiary: $ Vision Insurance $ $ Children’s portion: Disability Insurance Other Insurance (specify) $ $ $ Children’s portion: $ $ YOUR OTHER EXPENSES Dry Cleaning & Laundry $ Publications $ Clothing $ Dues, Clubs $ Medical / Dental / Prescription $ Religious & Charities $ Your Gifts (special holidays) $ Pet expenses $ Entertainment $ Alimony Paid to Former Spouse $ Recreational Expenses (e.g., fitness) $ Child Support Paid for other children $ Vacations $ Travel Expenses for Visitation $ (out-of-pocket uncovered expenses) Date of initial CS order: Other (attach sheet to list) TOTAL ABOVE MONTHLY EXPENSES (also write on first line of 2C on page one) Domestic Relations Financial Affidavit - rev. DRAFT January 8, 2007 Provided by the DeKalb County Superior Court and the Atlanta Legal Aid Society $ $ Page 5 of 6 American LegalNet, Inc. www.FormsWorkflow.com (5)(B) Y OUR P AYMENTS & D EBTS TO C REDITORS To Whom Balance Due Monthly Payments $ $ $ $ $ Wife $ $ Husband $ $ Joint $ $ (Please check one) $ Total Monthly Payments to Creditors (also write this total on line 2 of 2C on page one) $ (5)(C)TOTAL MONTHLY EXPENSES (Total Expenses from final line on page 5 + Total Monthly Payments to Creditors above) (also write this total on line 3 of 2C on page one) G Plaintiff G Defendant $ Pro se (Sign in front of notary public.) Name: Address: Daytime Phone: ( ) Subscribed and sworn before me on , 20 . Notary Public pro se DR $ Affidavit for new USCR24 approved corrected 2.wpd Domestic Relations Financial Affidavit - rev. DRAFT January 8, 2007 Provided by the DeKalb County Superior Court and the Atlanta Legal Aid Society Page 6 of 6 American LegalNet, Inc. www.FormsWorkflow.com