IN THE CIRCUIT COURT OF THE TWELFTH JUDICIAL CIRCUIT WILL COUNTY, ILLINOIS IN RE THE DISSOLUTION OF: Plaintiff vs Case No.: ______________________ Defendant INCOME/EXPENSE AFFIDAVIT -------------- - - - - - - - - - - - - - ,· on oath, states: 1. The parties have been married/joined 2. There are 3. I (am) years; my age is years old. _ children of the marriage/union, ages: (am not) residing in the marital/joined residence. 4. My customary monthly living expenses are: Rent/Mortgage( s) House Insurance Tax Escrow Food (for people) Doctors/Dentists Prescriptions Lien Payment on Auto Gas, Oil, Maintenance Auto Insurance/Month Utilities: Gas Electric Water and Garbage Telephone Cable Life Insurance Clothes (for people) Grooming (Personal) Children(s) School: Tuition Books Lunch programs Babysitter Clubs/Entertainment Gifts/Donations Vacations Children's Activities $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ ANDREA LYNN CHASTEEN, CLERK OF THE CIRCUIT COURT OF WILL COUNTY Original - Court Copy -Plaintiff Copy - Defendant 8A - Part 1(Revised 12/01/2016) American LegalNet, Inc. www.FormsWorkFlow.com Miscellaneous: $ $ $ $ $ $ $ Total fixed monthly expenses Total minimum credit bill payments Total expenses 5. My total gross income last calendar year was My Federal tax refund last calendar year was 6. My employer is The address of my employer is _______________________________________________ I earn $ is (Weekly) per hour and work (Semi-Monthly) (Bi-Weekly) hours per pay period; my pay period (Monthly). Number of exemptions I claim is____ Gross Income Monthly Less: Federal Withholding State Withholding FICA Union Dues Mandatory Retirement Mandatory Hospital Insurance Court Ordered Support I Pay Other: $ $ $ $ $ $ $ $ $ $ $ $ $ $ Total "statutory" deductions Net income per month Other income from all sources Total income from all sources (Ex: e.g., bonus, interest, rent, etc.) 7. ASSETS A. Real estate: FAIR MARKET VALUE DEBT B. Vehicles: ANDREA LYNN CHASTEEN, CLERK OF THE CIRCUIT COURT OF WILL COUNTY Original- Court Copy -Plaintiff Copy -Defendant 8A - Part 2 (Revised 12/01/2016) American LegalNet, Inc. www.FormsWorkFlow.com ASSETS C. Bank Accounts: FAIR MARKET VALUE DEBT D.Employment Benefits: (Include Past and Present Employers) E. Other Assets: (of any descriptions whatsoever) 8. LIABILITIES A. Mortgages: BALANCE PAYMENT B. Auto Loans: C. Credit Cards: D. Unpaid Medical Bills: E. Other Loans: F. Educational Loans: Under penalties of perjury as provided by law pursuant to Section 1-109 of the Code of Civil Procedure, I certify the statements set forth in this instrument are true and correct. Date ANDREA LYNN CHASTEEN, CLERK OF THE CIRCUIT COURT OF WILL COUNTY Copy -Plaintiff Copy -Defendant American LegalNet, Inc. www.FormsWorkFlow.com Signature of Affiant Original - Court 8A - Part 3 (Revised 12/01/2016)