CIRCUIT COURT FOR THE TWENTY-THIRD JUDICIAL CIRCUIT KENDALL COUNTY, ILLINOIS Case Number_____________ Petitioner: ________________________________________ Respondent: ______________________________________ AFFIDAVIT OF INCOME & EXPENSES A. Name: ____________________________________________________ B. Date of Marriage: ____________________ C. Children of the Parties (names & ages): ________________________________________________________________ ________________________________________________________________________________________________________ D. Custodial Parent: _______________________________________ E. Are Parties Separated? ___________________ F. Monthly Income (if paid weekly, multiply by 52 and divide by 12 to get monthly figures): Place of Employment:________________________________________________ Monthly Gross: _________________ Federal Income Tax: ____________________ State Income Tax: _________________ F.I.C.A.: ________________ Other Involuntary Deductions (specify): _______________________________________________________________ Voluntary Deductions (specify): _______________________________________________________________________ Number of Exemptions Claimed: ________ Income from other Sources (specify): ___________________________ ________________________________________________ Monthly Net Income: ________________________________ G. Cash on Hand (savings, checking, etc.): ________________________________________________________________ ________________________________________________________________________________________________________ H. Basic Household Monthly Expenses: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Rent or Mortgage:___________________ House/Renters Ins. _________________ Real Estate Taxes: __________________ Gas (house): ________________________ Electric: ___________________________ Water/Garbage: ____________________ Telephone: _________________________ Car: Plates/sticker/repair: ___________ Gas (car): __________________________ Car Payment:_______________________ 11. 12. 13. 14. 15. 16. 17. 18. 19. Car Insurance: ___________________________ Child Care: ______________________________ Education (specify): _______________________ Food:_____________________________________ Medical/Dental: __________________________ Clothing: _________________________________ Other Ins. (specify): _______________________ Recreation & Travel: ______________________ Cosmetic/Drugs/Beauty Care: ______________ 20. Other monthly creditor payments (specify creditor, balance & monthly payments 21. Miscellaneous (specify): TOTAL: STATE OF ILLINOIS } SS COUNTY OF KENDALL _____________ Under penalties as provided by law pursuant to Section 1-109 of the Code of Civil Procedure, the undersigned certifies that the statements set forth in this instrument are true and correct, except as to matters therein stated to be on information and belief and as to such matters the undersigned certifies that he/she verify believes the same to be true DATE: __________________________________ __________________________________________________ Signature of Party 10/13 American LegalNet, Inc. www.FormsWorkFlow.com CC10