IN THE SUPERIOR COURT OF FULTON COUNTY STATE OF GEORGIA FAMILY DIVISION ___________________________, : : Petitioner, : : CIVIL ACTION FILE v. : : NO. ________________ ___________________________, : : Respondent. : : DOMESTIC RELATIONS FINANCIAL AFFIDAVIT You are required to make to the Court, under oath, a FULL DISCLOSURE of your income, net worth and financial condition on this form. Fill out each and every section of this form. If something does not apply to your situation, write, "N/A". 1. Your Name:________________________________ DOB ______________ Address:_______________________________________ County: ________________ City: _______________________ State: _____________ Zip Code: _______________ Spouse's Name:_____________________________ DOB ______________ Address: _______________________________________ County: ________________ City: _______________________ State: _____________ Zip Code: _______________ Date of Marriage:___________________________ Date of Separation:__________________________ Names and birth dates of children for whom support is to be determined in this action: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Names and birth dates of your other children who are living with you: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Names and birth dates of the children for which you are obligated to pay support by a court order: American LegalNet, Inc. www.FormsWorkflow.com __________________________________________________________________________ __________________________________________________________________________ ____________________________________________________________________ 2. EMPLOYMENT AND INCOME Occupation: ________________________________________________________ Employed By: ________________________________________________________ Number of exemptions claimed: __________________________________________ Pay period (ie, weekly, monthly, etc.) _____________________________________ If you are employed, but expecting soon to become unemployed or change jobs, describe the change you expect and why and how it will affect your income. If currently unemployed, describe your efforts to find employment, how soon you expect to be employed, and the pay you expect to receive: ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ______________________________________________________________________ EXCEPT IN PROCEEDINGS FOR ADOPTION, ENFORCEMENT, CONTEMPT, AND INJUNCTIONS FOR DOMESTIC OR REPEAT VIOLENCE, ALL OF THE FOLLOWING MUST BE ATTACHED TO THE COPY OF THIS FINANCIAL AFFIDAVIT SERVED ON THE OPPOSING PARTY. THE ATTACHMENTS SHALL NOT BE FILED WITH THE COURT: Your three (3) most recent pay stubs, your three (3) most recent Federal and State tax returns, and the most recent W-2 forms. If last year's Federal income tax return has not yet been filed, attach W-2s, 1099s, K-1s, and any other document to be attached to your tax return. If the attachments are not made to the copy served on the opposing party, an explanation is required. 3. SUMMARY OF YOUR INCOME AND NEEDS (a) (b) (c) (d) Gross monthly income (from Item 4A) Total income taxes paid on above income (Incl. Fed., State and FICA) Net monthly income (from Item 4C) Expenses Average monthly expenses (Item 5A) Monthly payments to creditors (Item 5B) TOTAL monthly expenses and payments to creditors (Item 5C) $ ____________ $ ____________ $ ____________ $ ____________ $ ____________ $ ____________ Domestic Relations Financial Affidavit Fulton County Family Division American LegalNet, Inc. www.FormsWorkflow.com 4. YOUR MONTHLY INCOME A. Gross Income (All income whether earned or unearned, from any source, must be entered based on monthly average regardless of date of receipt. Salary or Wages $ ____________ Bonuses, Commissions, Allowances, Fees, Overtime, Tips and similar payments (based on past 12-month average or time of employment if less than 1 year) $ ____________ Income from sources such as selfemployment, partnership, close corporations and independent contracts (gross receipts minus ordinary and necessary expenses required to produce income) ATTACH SHEET ITEMIZING YOUR CALCULATIONS. $ ______________ Severance Pay $ ______________ Disability/Unemployment/Worker's Compensation $ ______________ Recurring Income from Pension and Retirement Plans or Annuity payments $ ______________ Social Security benefits $ ______________ Other public benefits (do NOT include means-tested public assistance such as TANF or food stamps) $ ______________ $ ______________ Spousal or child support from people not in this case $ ______________ Interest and Dividends $ ______________ Rental income (gross receipts minus ordinary and necessary expenses required to produce income) ATTACH SHEET ITEMIZING YOUR CALCULATIONS $ ______________ Reimbursed expenses and In kind payments to the extent they reduce personal living expenses $ ______________ Fringe Benefits (if significantly reduce living expenses) $ ______________ Income from Royalties, Trusts or Estates $ ______________ Capital Gains or Gains derived from dealing in property (not including non-recurring gains) $ ______________ Prizes/Lottery Winnings $ ______________ Gifts (cash or other liquid assets or which can be converted to cash) $ ______________ Judgments from Personal Injury or other civil cases where cash is received on a recurring basis $ ______________ Assets used for support of family $ ______________ Other income of a recurring nature (specify source) $ ______________ Gross Monthly Income $ ______________ Domestic Relations Financial Affidavit Fulton County Family Division American LegalNet, Inc. www.FormsWorkflow.com B. Benefits of Employment List and describe (where requested below) all benefits of employment not deducted from your wages or salary. These are defined as those costs paid directly by your employer on your behalf. Most, if not all, of these bene