STATE OF ILLINOIS IN THE CIRCUIT COURT OF THE 17TH JUDICIAL CIRCUIT COUNTY OF WINNEBAGO IN RE THE MARRIAGE OF ] ] ] ] ] ] ] ] ] Plaintiff Vs. CASE NO.: Defendant I, FINANCIAL AFFIDAVIT OF NON-MINOR CHILD , on oath state the following: That my present age is When at school, I live at When not at school, I live at . # mos. # mos. . . 1. MONTHLY LIVING EXPENSES: ESTIMATED MONTHLY BUDGET Rent or House Payment Renter's Insurance Electricity Gas Heating Oil Telephone Groceries/Household Supplies Haircuts/Beauty Shop Car Insurance Gas, Oil and Repairs Personal Items Clothing Cable TV Cleaning and laundry Entertainment Health Insurance paid by child Uninsured doctors Uninsured dentists Uninsured Pharmaceutical Other uninsured expenses (specify) WHEN IN SCHOOL $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ WHEN NOT IN SCHOOL $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ A-23 APPENDIX U Page 1 7/99 2002 © American LegalNet, Inc. 1. Monthly Living Expenses - Continued School Expenses Fraternity/Sorority Fees Travel Other (specify) $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Installment Debts from #2 below TOTAL MONTHLY LIVING EXPENSES: 2. DEBTS: Scheduled Payment Per Month $ $ $ $ $ $ Actual Payment Per Month $ $ $ $ $ $ $ To Whom Owed (a) (b) (c) (d) (e) (f) Purpose Car Payment Balance Owed $ $ $ $ $ $ TOTAL PAYMENTS TO CREDITORS: 3. SCHOOL INFORMATION AND EXPENSES (If available, attach school estimate of yearly anticipated expenses, bills and receipts of payments made, class schedule and grading statement listing most recent and cumulative GPA.) Name of college, university or trade school Address . Course of study Month & year began Expected date of graduation Status: [check] 1st Year 2nd Year 3rd Year 4th Year Other Most Recent Semesters Completed ____ Credit Hours Earned ____ Cumulative GPA ____ Semester GPA ____ A-23-1 APPENDIX U Page 2 7/99 2002 © American LegalNet, Inc. 3. School Information and Expenses - Continued TUITION Fall Spring Summer BOOKS/SUPPLIES Fall Spring Summer FEES Fall Spring Summer ROOM AND BOARD; Fall Spring Summer $ $ $ $ $ $ $ $ $ $ $ $ $ TOTAL PER ACADEMIC YEAR 4. FINANCIAL AID (Attach all documentation) Subsidized Student Loans (payment deferred) Fall Spring Summer $ $ $ Unsubsidized Student Loans (payment not deferred) Fall Spring Summer Grants Fall Spring Summer A-23-2 $ $ $ APPENDIX U Page 3 7/99 $ $ $ 2002 © American LegalNet, Inc. 4. Financial Aid - Continued Scholarships Fall Spring Summer Work Study Aid Fall Spring Summer $ $ $ $ $ $ TOTAL AID: 5. RECAPITULATION $ TOTAL COSTS - Academic year or semester (designate) LESS AID BALANCE - of out-of-pocket expenses per academic year or Per semester (designate) 6. INCOME AND ASSETS (Attach W2's, 1099's, tax returns, etc.) A. School year employer: Address Number of weeks of employment per year Payroll Deductions: Hours of employment Withholding status Hourly wage Weekly gross income Net weekly income $ $ $ Federal taxes withheld State taxes withheld FICA withheld Medicare withheld Medical insurance Other Total Deductions A-23-3 APPENDIX U Page 4 7/99 2002 © American LegalNet, Inc. 6. Income and Assets - Continued B. Summer and recess employer if different from above: Address Number of weeks of employment per year Payroll Deductions: Hours of employment Withholding status Hourly wage Weekly gross income Net weekly income Federal taxes withheld State taxes withheld FICA withheld Medicare withheld Medical Insurance Other Total Deductions C. Other sources of annual income or cash receipts: Description 1. 2. 3. 4. Dividends Interest Other support received; gifts, trusts, etc. Other $ $ $ $ Amount per per per per Frequency D. Savings Accounts Description Location Acct. No. Balance A-23-4 APPENDIX U Page 5 7/99 2002 © American LegalNet, Inc. 6. Income and Assets - Continued E. Assets (e.g. stocks, bonds, investment accounts, trust beneficiary, vehicles, etc.) Attach statements if available. Asset Location $ $ $ $ $ Value as of (date) as of as of as of as of as of A Non-Minor Child VERIFICATION BY CERTIFICATION 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 Non-Minor Child) (Date) A-23-5 APPENDIX U -6- 7/99 2002 © American LegalNet, Inc.