IN THE CIRCUIT COURT FOURTH JUDICIAL CIRCUIT MONTGOMERY COUNTY , ILLINOIS IN RE: THE MARRIAGE OF ________________________) ________________________) No: _____________________ _______________________________) Petitioner VS ___________________________) _______________________ ) _______________________ ) Respondent FINANCIAL AFFIDAVIT _____________________________, on oath states that my age is _______, and that: If Pre-Judgment: 1. (a) Date of Marriage______________ Date of Separation_________________ Child Support Maintenance Paid since separation: $_____________ $_____________ If Post-Judgment: 1. (a) Date of Dissolution ______________________ Date of Separation ______________________ C/S Maint. (Per week, month) Ordered to be paid: $_________ $_________ _________________ Paid since Dissolution $_________ $_________ _________________ Order has been amended _______________times. Now being paid: $_________ $_________ _________________ Current Arrearage $_________ $_________ _________________ 2. There are _______children of the marriage, as follows: NAME AGE DATE OF BIRTH IN CUSTODY OF ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com 3. I have additional persons dependent on me for support as follows: NAME AGE DATE OF BIRTH RELATIONSHIP : _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 4. Present Employment____________________________________________________ Address______________________________________________________________ Hours of Employment __________________________________________________ Payroll Deductions Hourly Wage $ ___________ (a) Taxes $ ___________ Weekly Gross Income $ ___________ (b) Soc. Sec. $ ___________ Total Deductions $ ___________ (c) Medical Ins. $ ___________ Take Home Pay $ ___________ (d) Credit Union $ ___________ Number of Dependents Claimed _______ (e) Other $ ___________ TOTAL DEDUCTIONS $ ___________ 5. My MONTHLY living expenses are as follows: (Rent) or (House Payment) $__________ Electricity $_______________________ Car Ins. $_____________________________ Gas $____________________________ Gas, Oil & Repairs $____________________ Heating Oil $______________________ Hosp./Med. Ins. $______________________ Water $ _________________________ Life Ins. $_____________________________ Telephone $_______________________ Personal Items $_______________________ Trash Collection $__________________ Doctors $_____________________________ Sewer Charge $____________________ Dentists $_____________________________ Groceries/Household $_______________ Hospital $_____________________________ Restaurant Meals $__________________ School (Meals/Supplies) $________________ Charitable Contributions $____________ Cleaning & Laundry $___________________ Haircuts/Beauty Shop $______________ Entertainment $________________________ Union Dues $______________________ Gifts for Children $_____________________ Child Care $_______________________ Other $_______________________________ TOTAL MONTHLY LIVING EXPENSE $________________________ American LegalNet, Inc. www.FormsWorkFlow.com 6. Debts: (Payments to creditors other than noted at Paragraph No. 5 above) To Whom: (a) ______________ (b) ______________ (c) _____________ (d) ______________ (e) ______________ (f) ______________ (g) ______________ (h) ______________ (i) ______________ (j) ______________ (k) ______________ Purpose: Monthly Payment: Balance: Car Payment $_________________ $_________________ Furniture/Appliance $_________________ $_________________ Credit Card $_________________ $_________________ Credit Card $_________________ $_________________ __________________ $_________________ $_________________ __________________ $_________________ $_________________ __________________ $_________________ $_________________ __________________ $_________________ $_________________ __________________ $_________________ $_________________ __________________ $_________________ $_________________ __________________ $_________________ $_________________ $_________________ $_________________ TOTALS 7. Assets: (List all cash, certificates of deposit, savings, checking and Credit Union Accounts, bonds, stocks, household goods and appliances, motor vehicles, boats, real estate, and all other property, real or personal, owned by you.) Description: Location: Co-Owners Names: (a)________________ (b)_______________ __________________ __________________ Fair Cash/ Market Value: $_____________ $_____________ (c)________________ (d)________________ __________________ __________________ $_____________ $_____________ ______________ ______________ (e)________________ (f)________________ (g)_______________ __________________ __________________ __________________ $_____________ $_____________ $_____________ ______________ ______________ ______________ (h)________________ __________________ $_____________ ______________ (i)_________________ __________________ $_____________ ______________ ______________ ______________ American LegalNet, Inc. www.FormsWorkFlow.com Type: RETIREMENT FUND Company: Contributory/ Non-contributory: (a)_______________ (b)_______________ ___________________ _______________ ___________________ _______________ Type: Present Value: $_________________ $_________________ LIFE INSURANCE Company: Beneficiary: Present (a)________________ (b)________________ 8. Other Income: __________________ __________________ _______________ _______________ Value: $_________________ $_________________ Source:__________________________Amount$________________ Source:__________________________Amount $________________ I have read the foregoing; together with _____attached sheets following hereafter, and same are true and correct. _________________________________________ Signature Subscribed and sworn to before me, this________day of ___________, 20____ _________________________________ Notary Public/ Circuit Clerk This form prepared by________________________ Attorney for________________________________ American LegalNet, Inc. www.FormsWorkFlow.com