In The Circuit Court For The Seventh Judicial Circuit of Illinois Sangamon Cpunty, Springfield, Illinois (PetItIOner) Case No. vs. _ (Defendant} AFFIDAVIT OF INCOME AND EXPENSES, ASSETS AND LIABILITIES _ _ _ _ _ _ _ _ _ _ _ _ _ _ _, PlaintifflDefendant, states as follows: Telephone number:. Name: Address: _ Date of marriage (if applies): _ Date of Birth: Date of Separation: _ _ Dependent children of this relationship: MlF d/olb:. lives with _ MlF d/olb:. lives _ M/F d/olb: .lives with. _ M/F d/olb: with, _ _ Other employer Number of paychecks per year (circle one): 12 Single 24 Address: _ Address: Current employer Withholding status: Married ~-lives with~ _ 26 52 Other _ Number of exemptions claimed Other dependents: Relationship _ Other dependents: Relationship _ Form 25 American LegalNet, Inc. www.FormsWorkflow.com STATEMENT OF MONTHLY INCOME Gross income ti-c1111 all sources last calendar year: $ _ Gross income ii'om all sources year to date. through ,(date):$. _ Gross monthly income (if paid weekly, mUltiply be 4.33, if paid bi-weekly multiply by 2.17): S,t1ary: $- - - - - - - - - Overtime: $ Bonus: $- - - - - - - - Draw: $ Disability: $- - - - - - - - ­ Social Secunty: $ U nem pi oylll en t: $-------­ Rental I nCllmc: $ I)uhlic Aid: $ _ Investment: $ Business: $ _ Partnership: $ Mall1tenanee: .$ _ Other: $ --­ $ Total gross monthly income: Additional· . _ Child Support: $ Statutory deductions: reeler'll lax: $ _ Stale lax: $ _ Social Security: $ _ Medicare: $ _ Mandatory retircmcnt contrihutions: $ _ Medical Insurance: $. Union dues: $ Prior obligations of child support actually heing paid: $ _ Other (specify) $ _ _ STATEMENT OF MONTHLY LIVING EXPENSES as 01' (Do not duplicate, list only under one category) _ 1. Household Expenses Mortgagelrental (circle one) $,--------------­ American LegalNet, Inc. www.FormsWorkflow.com Household expenses (continued) Home equity loan/second mortgage $ -------------­ , Real estate taxes $,--------------­ Homeowners or renter's insurance $,--------------­ Heatlfue1 $,--------------­ Electricity $--------------­ Telephone $,--------------­ Cell phone $,--------------­ Cable television $---------------­ Water and sewer $- - - - - - - - - - - - - - - - - Computer/internet $-------------­ Garbage removal $,-------------­ Laundry/dry cleaning $ Household maintenance $,--------------­ Food and household supplies $--------------­ Eating out $-------------­ Other (specify) _ $-------------­ Total household expenses: 2. TranspOliation (number ofvehicles $'--------------­ -----') Insurance/license $,-------------­ Gasoline $,------------­ Repairs $- - - - - - - - - - - - - - Other transportation $- - - - - - - - - - - - - - Total transportation expenses: $,------------­ 3. Persona1 Clothing $-------------­ Grooming(hair care/cosmetics/etc.) $ Medical (after insurance) $------------­ Doctor $--------------­ Dentist $,--------------­ -------------­ American LegalNet, Inc. www.FormsWorkflow.com Personal (continued) Prescribed medicine $, Counseling $, _ Life insurance premiums $, _ Medical insurance (not withheld from pay) $, _ Dental insurance (not withheld from pay) $, _ $, _ Clubs/entertainment $ _ Newspaper/magazines $ _ Gifts $- - - - - - - - - - - - - - - - Donations $ _ Vacations $ _ Voluntary contributions to retirement pension $ _ Other (specify) $ _ Total miscellaneous expenses: $, _ 5. Children's separate expenses (identify special needs) Clothing $ _ Grooming $ _ Education $ _ Total personal expenses: _ 4, Miscellaneous Tuition $ Books/fees $ Lunches $- - - - - - - - - - - - - - - - Transportation $ _ Activities $ _ Allowance $ _ Child care/before and after school care $ _ Lessons and supplies $ _ Summer camps $, _ _ American LegalNet, Inc. www.FormsWorkflow.com Children's expenses (continued) Vacation $,--------------­ Entertainment $,-------------­ Other (specify) _ $--------------­ Total children separate expenses: $,--------------­ TOTAL MONTHLY LIVING EXPENSES $,----------------­ STATEMENT OF DEBTS - use additional sheets if necessary Creditor Purpose Balance Due Monthly payment STATEMENT OF ASSETS· use additional sheets if necessary Real estate: Address Ownership Possessed by Value Ownership Possessed by Value Motor vehicles: Vehicle American LegalNet, Inc. www.FormsWorkflow.com Retirement accounts: Plan llame Ownership Value Ownership Type of plan Balance Bank/credit union accollnts: Typc of account Bank Life illsUl-ancc: Company Death bencfit Beneficiary Owner Whole/term I Value I Ownership Description Possessed by Value , I Under penalties as provided by law pursuant to Section 1-109 of the Code of Civil Procedurc, the undersigned hereby certifies that the statements set forth in the foregoing Affidavit are true and correct Datc: _ Affiant American LegalNet, Inc. www.FormsWorkflow.com