STATE OF ILLINOIS IN THE CIRCUIT COURT OF THE 17TH JUDICIAL CIRCUIT COUNTY OF WINNEBAGO @ IN RE THE MARRIAGE OF Plaintiff, and Defendant. Case No. FINANCIAL AFFIDAVIT INSTRUCTIONS [1] All questions require a written response. If you do not have the information requested or do not know the answer to a particular question, indicate that as your answer. [2] Use additional sheets if necessary Plaintiff/Defendant, being duly sworn states that the following is an , of his/her income from all sources, a statement accurate statement as of of monthly living expenses and debts and a statement of health insurance coverage. Name: Telephone Number Address: Date of Birth Date of Dissolution of Marriage Date of Marriage (if applicable) Date of Separation Dependent Children of this Marriage: d.o.b. residing with d.o.b. residing with d.o.b. residing with d.o.b. residing with Current Employer Address: Self-employment Address Other employment Address G Check Tif unemployed A-15 APPENDIX O 04/03 American LegalNet, Inc. www.FormsWorkflow.com APPENDIX O - Continued Number of paychecks per year (Please check T) G 12 G 24 G 26 G 52 G Other Number of exemptions claimed Withholding Status GM GS Number of dependents Gross income from all sources last year: Gross income from all sources this year through $ (Year) Gross Monthly Income (Compute as 4.33 if paid weekly or 2.17 if paid bi-weekly) Salary/wages/base Pay Overtime/commission $ Bonus $ Draw $ Pension and Retirement Benefits $ Annuity $ Interest/dividend Income $ Trust Income $ Social Security Payments $ Unemployment Benefits $ Disability Payments / Workers Compensation $ Public Aid / Food Stamps $ Rental Income $ Business Income $ Partnership Income $ Royalty Income $ Fellowship / Stipends $ Other Income (specify) $ Total Gross Monthly Income: A-15.1 $ $ APPENDIX O -2- 4/03 American LegalNet, Inc. www.FormsWorkflow.com APPENDIX O - Continued Additional Cash Flow (Monthly) Maintenance received (Payments received from prior Judgment or support orders in other actions); $ Child support received (Payments received pursuant to Court order or voluntarily in this or other actions) $ Total Additional Cash Flow $ TOTAL MONTHLY GROSS INCOME FROM ALL SOURCES $ Statutory Monthly Deductions Federal Tax (based on withholding status) $ State Tax (based on withholding status) $ 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 MONTHLY INCOME $ MONTHLY INCOME A-15.2 $ $ APPENDIX O -3- 04/03 American LegalNet, Inc. www.FormsWorkflow.com APPENDIX O - Continued STATEMENT OF MONTHLY LIVING EXPENSES as of (Do not duplicate; list only under one category) 1. Household a. Mortgage or Rent (specify) $ b. Home Equity Loan / Second Mortgage $ c. Real Estate Taxes, Assessments $ d. Homeowners or Renters Insurance $ e. Heat /Fuel $ f. $ Electricity g.. Telephone (include long distance) $ h. Cell Phone / Pager $ i. Cablevision $ j. Water and Sewer $ k. Computer $ l. $ Refuse Removal m. Laundry / Dry Cleaning $ n. Maid / Cleaning Service $ o. Furniture and Appliance Repair/Replacement $ p. Lawn and Garden / Snow Removal $ q. Food (groceries, household supplies, etc.) $ r. Restaurant Meals $ Other (specify) $ $ SUBTOTAL HOUSEHOLD EXPENSES A.15.3 APPENDIX O -4- $ 04/03 American LegalNet, Inc. www.FormsWorkflow.com APPENDIX O - Continued 2. Transportation (Number of vehicles ) a. Gasoline $ b. Repairs $ c. Insurance / License / City Stickers $ d. Alternative Transportation $ e. Other (specify) $ SUBTOTAL TRANSPORTATION EXPENSES: $ 3. Personal a. Clothing $ b. Grooming $ c Medical (after insurance proceeds): (1) Doctor $ (2) Dentist $ (3) Optical $ (4) Medication $ (5) Counseling $ (6) Other $ d. Insurance: (1) Life Insurance Premiums $ (2) Medical/Hospitalization Insurance Premiums (Not withheld from wages) $ (3) Dental/Optical Insurance Premiums (Not withheld from wages) $ e. Other (specify) $ $ $ $ SUBTOTAL PERSONAL EXPENSES: A-15.4 $ APPENDIX O -5- 04/03 American LegalNet, Inc. www.FormsWorkflow.com APPENDIX O - Continued 4. Miscellaneous a. Clubs/Social Obligations/Entertainment $ b. Newspapers, Magazines, Books $ c. Gifts $ d. Donations, Church or Religious Affiliation $ e. Vacations $ f. $ Tax-deferred Contributions $ $ g. Other (specify) $ $ $ SUBTOTAL MISCELLANEOUS EXPENSES: $ 5. Children’s Separate Expenses: (Identify special needs ) a. Clothing $ b. Grooming $ c. Education: (1) Tuition $ (2) Books / Fees $ (3) Lunches $ (4) Transportation $ (5) Activities $ d. Medical (after insurance proceeds): (1) A-15.5 Doctor $ APPENDIX O -6- 04/03 American LegalNet, Inc. www.FormsWorkflow.com APPENDIX O - Continued (2) Dentist $ (3) Optical $ (4) Medication $ (5) Counseling $ e. Allowance $ f. $ Child Care/Before and After School Care g. Sitters $ h. Lessons and Supplies $ i. Clubs / Summer Camps $ j. Vacation $ k. Entertainment $ l. $ Other (Specify) $ SUBTOTAL CHILDREN’S EXPENSES: TOTAL MONTHLY LIVING EXPENSES $ STATEMENT OF DEBTS AND LIABILITIES CREDITOR PURPOSE BALANCE DUE MONTHLY PMT. TOTAL MONTHLY DEBT PAYMENT A-15-6 APPENDIX O -7- 04/03 American LegalNet, Inc. www.FormsWorkflow.com APPENDIX O - Continued STATEMENT OF HEALTH INSURANCE COVERAGE Currently effective health insurance coverage: G Yes G No Name of insured Name of insurance carrier: Policy or Group No. Type of insurance: G Medical G Dental G Optical Deductible: G Per Individual Persons covered: G Self G Spouse G Dependents Type of policy: G HMO G PPO G Standard Indemnity (i.e. 80/20) Provided by: G Employer G Private Policy G Other Group Monthly cost: G Paid by Employer G Paid by Employee: for dependents $ Per Family $ for myself RECAP MONTHLY INCOME TOTAL MONTHLY LIVING EXPENSES DIFFERENCE BETWEEN NET INCOME AND EXPENSES LESS MONTHLY DEBT PAYMENT INCOME AVAILABLE PER MONTH Signature of Party: $ $ $ $ $ G Plaintiff G Defendant Type or Print Name VERIFICATION BY CERTIFICATION I certify that all of the corroborating documents to this Financial Affidavit in my possession, or that I can obtain upon reasonable effort as of this date, have been provided to the opposing party. UNDER PENALTIES of perjury as provided by law pursuant to Section 1-109 of the Code of Civil Procedure, I certify 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 I certify as aforesaid that I verily believe the same to be true. (Signature of Party) (Date) PREPARED BY: A-15-7 APPENDIX O -8- 04/03 American LegalNet, Inc. www.FormsWorkflow.com