IN THE CIRCUIT COURT OF THE NINETEENTH JUDICIAL CIRCUIT LAKE COUNTY, ILLINOIS IN RE: The Marriage of: Custody of: Support of: ) ) ______________________________________ ) Petitioner ) and ) ) ______________________________________ ) Respondent ) No. ________________ FINANCIAL AFFIDAVIT 11.02 Affiant, ___________________________________________, having been duly sworn, upon oath, states that the information contained herein is true and correct as of , 20 Name: Telephone No: ( Address: Petitioner Date of Birth: ____________ (mmddyyyy) Respondent Date of Birth: ___________ (mmddyyyy) Date of Marriage: ___________________ (mmddyyyy) ) Date of Dissolution of Marriage: (if applicable) ____________ (mmddyyyy) Minor and/or Dependent Children of this Marriage: Date of Birth (mmddyyyy) Name Currently Living With (Attach additional page(s) as needed) Current Employer: Address: Self Employment: Address: Other Employment: Address: Check if unemployed Number of Paychecks per year: (Please Check box) 12 24 26 52 Other _______ Number of Exemptions claimed: _______________ Number of Dependents claimed: _______________ Gross Income from all sources last year: _______________________________________ Gross income from all sources this year through _______________: $ ______________ Date Page 1 of 6 171-12 FD33 (R01/06) American LegalNet, Inc. www.USCourtForms.com STATEMENT OF INCOME Gross Monthly Income Salary/Wages/Base Pay Overtime/Commission Bonus Draw Pension and Retirement Benefits Annuity Interest income Dividend income Trust income Social Security Unemployment benefits Disability payment Worker’s Compensation Public Aid/Food Stamps Investment income Rental income Business income (including non-taxable distributions) Partnership income Royalty income Fellowship/stipends Other income (specify): ________________________ TOTAL GROSS MONTHLY INCOME: $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Additional Cash Flow (Monthly) Spousal support received (specify) Pursuant to a prior judgment or order in another case Pursuant to a prior judgment or order in this case $ $ $ $ Voluntarily paid in this case Child Support received (specify) Pursuant to a prior judgment or order in another case Pursuant to a prior judgment or order in this case $ $ $ $ Voluntarily paid in this case Total additional cash flow: $ $ Required Monthly Deductions Federal Tax (based on __________ exemptions) State Tax (based on __________ exemptions) FICA (or Social Security equivalent) Medicare Tax Mandatory retirement contributions required by law or as condition of employment Union Dues (Name of Union: ___________________) Health/hospitalization Premiums Prior obligation(s) of support actually paid pursuant to Court order Other (specify): TOTAL REQUIRED DEDUCTIONS FROM INCOME: NET MONTHLY INCOME: Page 2 of 6 $ $ $ $ $ $ $ $ $ $ $ $ $ 171-12 FD33 (R01/06) American LegalNet, Inc. www.USCourtForms.com STATEMENT OF MONTHLY LIVING EXPENSES 1. Household a. Mortgage or rent (specify): b. Home equity loan payment c. Real estate taxes, assessments d. Homeowners or renters insurance e. Heat/fuel f. Electricity g. Telephone (include long distance) h. Water and Sewer i. Refuse removal j. Laundry/dry cleaning k. Maid/cleaning service l. Furniture and appliance repair/replacement m. Lawn and garden care/snow removal n. Food (groceries, household supplies, etc.) o. Liquor, beer, wine, etc. p. Other (specify): SUBTOTAL HOUSEHOLD EXPENSES: $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 2. Transportation $ $ $ $ $ a. Fuel b. Repairs/maintenance c. Insurance/license/city stickers d. Payments/replacement e. Other (specify): SUBTOTAL TRANSPORTATION EXPENSES: $ $ 3. Personal a. Clothing b. Grooming c. Medical (after insurance proceeds/reimbursement) (1) Doctor (2) Dentist (3) Optical (4) Medication d. Insurance (1) Life – Term/Whole (specify) (2) Medical/Hospitalization (3) Dental/Optical e. Other (specify) SUBTOTAL PERSONAL EXPENSES: $ $ $ $ $ $ $ $ $ $ $ $ 4. Miscellaneous: a. Clubs/social obligations/entertainment b. Newspapers, magazines, books c. Gifts d. Donations, church or religious affiliations e. Vacations f. Other (specify) SUBTOTAL MISCELLANEOUS EXPENSES Page 3 of 6 $ $ $ $ $ $ $ $ 171-12 FD33 (R01/06) American LegalNet, Inc. www.USCourtForms.com 5. Expenses of Minor and/or Dependent Children of this Marriage: a. Clothing b. Grooming c. Education (1) Tuition (2) Books/Fees (3) Lunches (4) Transportation (5) Medication d. Medical (after insurance proceeds/reimbursement) (1) Doctor (2) Dentist (3) Optical (4) Medication e. Allowance f. Child care/After-school care g. Sitters h. Lesson and supplies i. Clubs/Summer Camps j. Vacation k. Entertainment l. Other (specify) $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ SUBTOTAL CHILDREN’S EXPENSES: $ $ TOTAL MONTHLY LIVING EXPENSES: $ $ STATEMENT OF LIABILITIES CREDITOR’S NAME BALANCE DUE PAYMENT FOR TOTAL LIABILITIES $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ TOTAL MONTHLY DEBT SERVICE MONTHLY PAYMENT $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ (Attach additional page(s) as needed) Page 4 of 6 171-12 FD33 (R01/06) American LegalNet, Inc. www.USCourtForms.com STATEMENT OF ASSETS Valuation Date: _______________ Marital Residence and Other Real Estate: 1. Marital Residence at: 2. 3. 4. TOTAL CASH OR CASH EQUIVALENTS Market Value $ $ $ $ $ Cars & Other Personal Property: TOTAL CARS & OTHER PERSONAL PROPERTY: $ $ $ $ $ $ $ Businesses: TOTAL BUSINESSES $ $ $ $ $ $ $ Financial Assets (Cash or Cash Equivalents): Savings or interest-bearing accounts Checking Accounts Certificates of Deposit Money Market Accounts Cash Other (specify): Other (specify): TOTAL CASH OR CASH EQUIVALENTS 1. Retirement: 2. 3. 4. TOTAL RETIREMENT & DEFERRED COMPENSATION Page 5 of 6 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Market Value $ $ $ $ $ Investment Accounts and Securities: Stocks Bonds Tax exempt securities Other (specify): Other (specify): Other (specify): TOTAL INVESTMENT ACCOUNTS AND SECURITIES Debt Market Value Retirement & Deferred Compensation: 1. 2. 3. 4. 5. 6. Debt $ $ $ $ $ $ $ Market Value 1. Business Interest 2. 3. 4. 5. 6. 1. 2. 3. 4. 5. 6. 7. Debt $ $ $ $ $ Market Value 1. 2. 3. 4. 5. 6. (mmddyyyy) $ Market Value $ $ $ $ $ $ $ $ 171-12 FD33 (R01/06) American LegalNet, Inc. www.USCourtForms.com RECAP OF INCOME AND EXPENSES: Net Monthly Income Total Monthly Living Expenses Less Monthly Debt Service Total Income Available per Month (+) (-) (-) (=) $ $ $ $ STATEMENT OF HEALTH INSURANCE COVERAGE Currently effective health insurance coverage? Yes No Name of insurance carrier: _____________________________________________________________ Policy of Group No.: __________________________ Type of insurance: Medical Dental Optical Deductible: Per individual: $___________ Persons covered: Type of policy: Provided by: Self HMO Employer Spouse PPO Per family: $____________ Dependents Full indemnity Private Policy Other Group Paid by Employer Paid by employee: $ for dependents $ Monthly costs: for self VERIFICATION The foregoing Financial Affidavit has been carefully read by the undersigned who states under oath, under penalties as provided by law pursuant to 735 ILCS 5/109, that this affidavit includes all of his/her income and expenses, he/she has knowledge of the matters stated and he/she certifies that the statements set forth in this Affidavit are true and correct, except as to matters specifically stated to be on information and belief, and as to such matters the undersigned certifies as aforesaid that he/she believes same to be true. __________________________________ _________________________________ Signature of Petitioner Signature of Respondent __________________________________ _________________________________ Typed or Printed Name of Petitioner Typed or Printed Name of Respondent Date signed: _______________________ Date signed: _______________________ Page 6 of 6 171-12 FD33 (R01/06) American LegalNet, Inc. www.USCourtForms.com