DEKALB COUNTY SUPERIOR COURTSTATE OF GEORGIA ,Plaintiff,vs. ,Defendant.Civil Action Case Number DOMESTIC RELATIONS FINANCIAL AFFIDAVIT(1) Your Name:Your Age:Spouse222s Name:Spouse222s Age:Date of Marriage:Date of Separation:Names and year of birth of children for whom support is to be determined in this action:NameYear of BirthResides withNames and year of birth of your other children:NameYear of BirthResides with(2) SUMMARY OF YOUR INCOME AND NEEDS: (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. January 8, 2007 - Tech. Rev. 10-2015 & 5-2017Page 1 of 6Provided by the DeKalb County Superior Court and the Atlanta Legal Aid Society American LegalNet, Inc. www.FormsWorkFlow.com (3) (A) YOUR GROSS MONTHLY INCOME:(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 227 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$ Worker222s 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 andFICA) (also write in 2B on page one)$ Domestic Relations Financial Affidavit - rev. January 8, 2007 - Tech. Rev. 10-2015 & 5-2017Page 2 of 6Provided by the DeKalb County Superior Court and the Atlanta Legal Aid Society American LegalNet, Inc. www.FormsWorkFlow.com Your Pay Period (i.e., monthly, weekly, etc.):Number of Exemptions Claimedby You for Tax Purposes:(4) ASSETS(List all assets here, including both non-marital and marital property. If you claim or agree that allor part of an asset is non-marital, indicate the non-marital portion under the appropriate spouse222scolumn and state the amount and the basis: pre-marital, gift, inheritance, source of funds, etc. Thetotal value of each asset must be listed in the "value" column. "Value" means what you feel the itemof property would be worth if it were offered for sale.)DescriptionValueSeparateAsset ofHusbandSeparateAsset ofWifeBasis of the Claim(pre-marital, gift,inheritance, etc.)Cash$ $ $ Stocks, Bonds$ $ $ CD222s / Money Market Accounts$ $ $ Bank Accounts (list each account below): (1)$ $ $ (2)$ $ $ (3)$ $ $ Retirement Pensions, 401(k), IRA orProfit-Sharing$ $ $ Money Owed to You (or Spouse)$ $ $ Tax Refund Owed to You$ $ $ 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. January 8, 2007 - Tech. Rev. 10-2015 & 5-2017Page 3 of 6Provided by the DeKalb County Superior Court and the Atlanta Legal Aid Society American LegalNet, Inc. www.FormsWorkFlow.com (4) ASSETS (continued)DescriptionValueSeparateAsset ofHusbandSeparateAsset ofWifeBasis of the Claim(pre-marital, gift,inheritance, etc.)Life Insurance (net cash value)$ $ $ Furniture / Furnishings$ $ $ Jewelry$ $ $ Collectibles$ $ $ Other Assets (specify):$ $ $ $ $ $ $ $ $ TOTAL ASSETS$ $ $ (5)(A) AVERAGE MONTHLY EXPENSES FOR YOU AND YOUR HOUSEHOLDHOUSEHOLD EXPENSESMortgage or Rent Payments$ Gas$ Property taxes$ Repairs & Maintenance$ Homeowner222s / Renter222s Insurance$ Lawn Care$ Electricity$ Pest Control$ Water$ Cable TV / Internet Access$ Garbage & Sewer$ Misc. Household & Grocery Items$ TelephonesMeals Outside Home$ Residential Lines$ Other (specify)$ Cellular Telephones$ $ AUTOMOTIVEGasoline & 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. January 8, 2007 - Tech. Rev. 10-2015 & 5-2017Page 4 of 6Provided by the DeKalb County Superior Court and the Atlanta Legal Aid Society American LegalNet, Inc. www.FormsWorkFlow.com CHILDREN222S EXPENSESChild Care (total monthly cost)$ Allowance$ School Tuition$ Children222s 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$ Other Educational Expenses (list type & amount):Entertainment$ $ Activities (including extra-curricular,school, religious, cultural, etc.)$ $ Summer Camps$ OTHER INSURANCEHealth Insurance$ Life Insurance$ Children222s portion:$ Relationship of Beneficiary:Dental Insurance$ Disability Insurance$ Children222s portion:$ Other Insurance (specify)$ Vision Insurance$ $ Children222s portion:$ $ YOUR OTHER EXPENSESDry Cleaning & Laundry$ Publications$ Clothing$ Dues, Clubs$ Medical / Dental / Prescription (out-of-pocket uncovered expenses)$ 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$ Date of initial CS order:Travel Expenses for Visitation$ Other (attach sheet to list)$ TOTAL ABOVE MONTHLY EXPENSES (also write on first line of 2C on page one)$ Domestic Relations Financial Affidavit - rev. January 8, 2007 - Tech. Rev. 10-2015 & 5-2017Page 5 of 6Provided by the DeKalb County Superior Court and the Atlanta Legal Aid Society American LegalNet, Inc. www.FormsWorkFlow.com (5)(B)YOUR PAYMENTS & DEBTS TO CREDITORSTo WhomBalance DueMonthlyPayments(Please check one)JointHusbandWife$$ $$ $$ $$ $$ $$ 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)$ Subscribed and sworn before me on , 20 . Notary Public G Plaintiff G Defendant Pro se(Sign in front of notary public.) Name: Address: Daytime Phone: ( ) Email: pro se DR $ Affidavit for new USCR24 approved corrected 2 - Tech rev 2017-05.wpdDomestic Relations Financial Affidavit - rev. January 8, 2007 - Tech. Rev. 10-2015 & 5-2017Page 6 of 6Provided by the DeKalb County Superior Court and the Atlanta Legal Aid Society American LegalNet, Inc. www.FormsWorkFlow.com