DOMESTIC RELATIONS FINANCIAL AFFIDAVIT 1. AFFIANT’S NAME: Age Affiant’s Social Security No. (last 4 digits) Spouse’s Name: Age Date of Marriage: Date of Separation: Names and birth dates of children of this marriage: Name Date of Birth Resides With Names and birth dates of children of prior marriage/relationship residing with Affiant: Name Date of Birth 2. SUMMARY OF AFFIANT’S INCOME AND NEEDS Note: Summary data for 2(a), (b), (c) calculates automatically – begin with next section; Enter data for 2(d) and 2(e) manually (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 $ 3. A. AFFIANT’S GROSS MONTHLY INCOME (All income must be entered based on monthly average regardless of date of receipt. Where applicable, in come should be annualized.) Salary $ Bonuses, commissions, allowances, overtime, tips and similar payments (based on past 12-month average or time of employment is less than 1 year) ATTACH SHEET ITEMIZING THIS INCOME. $ Business income from sources such as self employment, partnership, close Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com corporations and/or independent contracts (gross receipts minus ordinary and necessary expenses required to produce income) ATTACH SHEET ITEMIZING THIS INCOME. $ Disability/unemployment/workers’ compensation $ Pension, retirement or annuity payments $ Social Security benefits $ Other public benefits (specify) $ 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 royalties, trusts or estates $ 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 Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com 4. ASSETS (If you can claim or agree that all or part of an asset is 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 Cash Stocks, bonds CD’s/Money Market Real Estate: home/other Automobiles Money owed you Retirement/IRA Furniture/furnishings Jewelry Life Insurance (cash value) Collectibles Bank accounts (list each account) Other assets: $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ TOTAL ASSETS $ $ $ 5B. PAYMENT TO CREDITORS (Out of sequence for formatting purposes) To Whom Balance Due $ $ $ $ $ $ $ $ $ $ $ $ $ Total Balance Due: Monthly Payments $ $ $ $ $ $ $ $ $ $$ $ $ $ Total Monthly Payments to Creditors $ C. TOTAL MONTHLY EXPENSES $ Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com 5 A. AVERAGE MONTHLY EXPENSES (Re-calculate weekly/annual expenses to a monthly average) HOUSEHOLD Mortgage or 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 home Other AUTOMOBILE Gasoline and oil Repairs Auto tags and license Insurance $ $ $ $ CHILDREN’S EXPENSES Child care School tuition School Supplies/expenses Lunch money Allowance Clothing Diapers Medical, dental, prescription Grooming/hygiene Gifts Entertainment Activities This $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ day of OTHER INSURANCE Health Life Disability Other $ AFFIANT’S OTHER EXPENSES Dry cleaning and laundry Clothing Medical/Dental Prescriptions Affiant’s gifts (special holidays) Entertainment Vacations Publications Dues, Clubs Religious, Charities Miscellaneous (attach sheet) Other (attach sheet) Alimony paid to former spouse Child support paid to another TOTAL ABOVE EXPENSES , 20 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ . Notary Public Affiant Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com