IN THE CIRCUIT COURT FOR THE SECOND JUDICIAL CIRCUIT _______________________ COUNTY, ILLINOIS IN RE THE MARRIAGE OF: ___________________________, Petitioner, and ___________________________, Respondent. ) ) ) ) ) ) ) ) ) ) No. __________________ FINANCIAL AFFIDAVIT “ Pre-Judgment “ Post-Judgment I. INTRODUCTION I, _______________________, on oath state that my present age is ______, and that: (a) (PRE-JUDGMENT ONLY): The parties have been married for ______ years, were separated on ________________, ______, and since that time the obligor has paid $________ in child support and $________ in maintenance to the spouse: (b) (POST-JUDGMENT ONLY): The marriage of the parties was dissolved on _____________, ______. The obligor was ordered to pay $_________ child support and $_________ in maintenance to the spouse. The said order was amended ______ time(s) and the obligor is now paying $_______ in child support and $________ in maintenance. The obligor (is not) (is) presently in arrears in the sum of $________. financial affidavit 5 Rev.8/17/2011 American LegalNet, Inc. www.FormsWorkFlow.com II. PARTIES AND CHILDREN WIFE HUSBAND Name: _______________________ Name: ________________________ Address: _______________________ Address: ___________________________ _______________________ Soc. Sec. #: XXX-XX-___ ___ ___ ___ _______________________ Soc. Sec. #: XXX-XX-___ ___ ___ ___ Date of Birth: _____________ Age: _____ Date of Birth: ______________ Age: ________ Employer: _______________________ Employer: ___________________________ Occupation: _______________________ Occupation: ___________________________ CHILDREN Name Date of Birth Age With Whom Residing ____________________ ____________ ________ ___________________________ ____________________ ____________ ________ ___________________________ ____________________ ____________ ________ ___________________________ ____________________ ____________ ________ ___________________________ III. STATEMENT OF INCOME. IMPORTANT: Attach most recent of last three months= pay stubs showing your year-to-date earnings and deductions. For those individuals who receive any income from self-employment sources, attach supporting documentation for year-to-date earnings. HUSBAND WIFE GROSS MONTHLY INCOME from: Salary, wages, commissions, bonuses, allowance & overtime (NOTE: To arrive at gross monthly income, multiply weekly gross by 52 and divide by 12, or multiply bi-weekly income by 26 and divide by 12) $_______________ $______________ Pension or retirement benefits $_______________ $______________ financial affidavit 5 Rev.8/17/2011 American LegalNet, Inc. www.FormsWorkFlow.com Social Security benefits $_______________ $______________ Disability or unemployment benefits $_______________ $______________ Public aid (ADC-Welfare) $_______________ $______________ Child support from prior marriage (alimony) $_______________ $______________ Rents $_______________ $______________ Other Income (specify): $_______________ $______________ _________________________ $_______________ $______________ _________________________ $_______________ $______________ TOTAL GROSS MONTHLY INCOME $_______________ $______________ Federal income tax withheld $_______________ $______________ State income tax withheld $_______________ $______________ Social Security withheld $_______________ $______________ Medical or other health-related insurance $_______________ $______________ Mandatory retirement contributions required as a condition of employment $_______________ $______________ Union Dues $_______________ $______________ Dependent and individual health/hospital insurance premiums $_______________ $______________ Prior Court ordered support and/or maintenance, actually paid pursuant to a Court Order $_______________ $______________ Other deductions permitted by 750 ILCS '505(a)(3)(h) C specify: $_______________ $______________ ___________________________ $_______________ $______________ ___________________________ $_______________ $______________ DEDUCTIONS: TOTAL NET MONTHLY INCOME $_______________ financial affidavit 5 $______________ Rev.8/17/2011 American LegalNet, Inc. www.FormsWorkFlow.com IV. ESTIMATED MONTHLY EXPENSES (*mark if a projected expense C Affiant must be prepared to submit testimony to support the same) HOUSEHOLD: Rent or house payment (specify) $__________________________ Repair and upkeep $__________________________ Housekeeper and yard work $__________________________ Homeowners= or renters= insurance $__________________________ Real estate taxes (not included in house payment) $__________________________ Other (specify): __________________________________ $__________________________ __________________________________ $__________________________ __________________________________ $__________________________ SUBTOTAL $__________________________ UTILITIES: Electricity $__________________________ Gas/Heating oil $__________________________ Water and sewer $__________________________ Telephone $__________________________ Trash removal $__________________________ Cable TV $__________________________ Other (specify): __________________________________ $__________________________ __________________________________ $__________________________ __________________________________ $__________________________ SUBTOTAL $__________________________ financial affidavit 5 Rev.8/17/2011 American LegalNet, Inc. www.FormsWorkFlow.com FOOD: Food, milk, household supplies $__________________________ School lunches $__________________________ Meals outside home $__________________________ Other (specify): __________________________________ $__________________________ __________________________________ $__________________________ __________________________________ $__________________________ SUBTOTAL $__________________________ CLOTHING: Clothing (self) $__________________________ Clothing (children) $__________________________ Laundry & dry cleaning $__________________________ Other (specify): __________________________________ $__________________________ SUBTOTAL $__________________________ MEDICAL CARE: (after insurance reimbursement) Doctor & Dentist (self) $__________________________ Drugs & medical supplies (self) $__________________________ Doctor & dentist (children) $__________________________ Drugs & medical supplies (children) $__________________________ Medical and dental insurance $__________________________ (do not list if already listed in III. on page 3 as a deduction from gross income) Other: __________________________________ $__________________________ __________________________________ $__________________________ SUBTOTAL $__________________________ financial affidavit 5 Rev.8/17/2011 American LegalNet, Inc. www.FormsWorkFlow.com TRANSPORTATION: Car payment $__________________________ Repair & maintenance $__________________________ Gas & oil $__________________________ Insurance $__________________________ License and registration $__________________________ Bus fare/parking $__________________________ Other (specify): __________________________________ $__________________________ __________________________________ $__________________________ SUBTOTAL $__________________________ MISCELLANEOUS: CHILD YOURS Child care/babysitter School & school supplies $______________ $______________ $______________ Church/charitable contributions $______________ Newspapers, magazines & books $______________ Barber/beauty shop $______________ $______________ Life insurance premiums $______________ Disability insurance premiums $______________ Professional dues $______________ Voluntary retirement contributions Allowance (children=s) $______________ Recreation/entertainment $______________ Family pets financial affidavit 5 $______________ $______________ $______________ Rev.8/17/2011 American LegalNet, Inc. www.FormsWorkFlow.com Family gifts $______________ Toiletries $______________ $______________ SUBTOTAL $______________ $______________ CREDITOR PAYMENTS NOT PREVIOUSLY LISTED: Monthly installment payments (credit cards): ___________________________________________________ $______________ ___________________________________________________ $______________ ___________________________________________________ $______________ ___________________________________________________ $______________ ___________________________________________________ $______________ Others (specify): ___________________________________________________ $______________ ___________________________________________________ $______________ ___________________________________________________ $______________ ___________________________________________________ $______________ SUBTOTAL: TOTAL AVERAGE MONTHLY EXPENSES: $______________ $______________ V. RECAP: NET MONTHLY INCOME $______________ TOTAL MONTHLY LIVING EXPENSES $______________ DIFFERENCE BETWEEN NET INCOME AND EXPENSES $______________ LESS MONTHLY DEBT SERVICE $______________ INCOME AVAILABLE PER MONTH $______________ financial affidavit 5 Rev.8/17/2011 American LegalNet, Inc. www.FormsWorkFlow.com VI. ASSETS (Designate each non-marital asset as ANM@) @ REAL ESTATE: DESCRIPTION __________________________ __________________________ __________________________ __________________________ __________________________ LOCATION ________________ ________________ ________________ ________________ ________________ PRESENT VALUE _______________ _______________ _______________ _______________ _______________ HOW TITLE HELD _______________ _______________ _______________ _______________ _______________ PRESENT VALUE _______________ _______________ _______________ _______________ _______________ HOW TITLE HELD _______________ _______________ _______________ _______________ _______________ MOTOR VEHICLES: DESCRIPTION (Year, make and model) ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ CASH AND FINANCIAL ACCOUNTS: (Banks, savings and loans and credit unions) PRESENT HOW DESCRIPTION LOCATION VALUE TITLE HELD __________________________ ________________ _______________ _______________ __________________________ ________________ _______________ _______________ __________________________ ________________ _______________ _______________ __________________________ ________________ _______________ _______________ __________________________ ________________ _______________ _______________ INVESTMENTS: (Stocks, bonds and other securities) DESCRIPTION __________________________ __________________________ __________________________ __________________________ __________________________ PRESENT VALUE _______________ _______________ _______________ _______________ _______________ HOW TITLE HELD _______________ _______________ _______________ _______________ _______________ CONTRIBUTORY NON-CONTRIBUTORY ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ PRESENT VALUE _______________ _______________ _______________ _______________ _______________ LOCATION ________________ ________________ ________________ ________________ ________________ RETIREMENT ACCOUNTS: TYPE __________ __________ __________ __________ __________ financial affidavit 5 COMPANY _____________________ _____________________ _____________________ _____________________ _____________________ Rev.8/17/2011 American LegalNet, Inc. www.FormsWorkFlow.com LIFE INSURANCE: TYPE __________ __________ __________ __________ COMPANY _______________ _______________ _______________ _______________ AMOUNT COVERAGE _______________ _______________ _______________ _______________ BENEFICIARY _______________ _______________ _______________ _______________ HOUSEHOLD GOODS, APPLIANCES AND ALL OTHER PROPERTY NOT LISTED: PRESENT DESCRIPTION LOCATION VALUE __________________________ ________________ _______________ __________________________ ________________ _______________ __________________________ ________________ _______________ __________________________ ________________ _______________ __________________________ ________________ _______________ CASH SURR. VALUE _______________ _______________ _______________ _______________ PREVIOUSLY HOW TITLE HELD _______________ _______________ _______________ _______________ _______________ VII. DEBTS: (Designate each non-marital debt as ANM@) @ NAME OF CREDITOR _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ PURPOSE _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ BALANCE _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ MONTHLY PAYMENT _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _____________________________________________ Signature Subscribed and sworn to before me this ______ day of _______________, 20_____. _____________________________________________ Notary Public financial affidavit 5 Rev.8/17/2011 American LegalNet, Inc. www.FormsWorkFlow.com