APPENDIX III Domestic Relations Affidavit IN THE IN THE MATTER OF JUDICIAL DISTRICT COUNTY, KANSAS ) ) ) ) ) ) ) ) ) ) and Case No. DOMESTIC RELATIONS AFFIDAVIT OF (name) 1. Mother’s Residence 2. Father’s Residence 3. Date of Marriage: 4. Number of Marriages: Mother Father 5. Number of children of the relationship: 6. Names, Social Security Numbers, birthdates, and ages of minor children of the relationship: Name Age Custodian American LegalNet, Inc. www.FormsWorkflow.com 7. Names, Social Security Numbers, and ages of minor children of previous relationships and facts as to custody and support payments paid or received, if any. Name Age Support Payment Custodian Paid or Rec’d $ $ $ $ 8. Mother is employed by Father is employed by (Name and address of employer) with monthly income as follows: A. Wage Earner 1. 2. 3. 4. 5. 6. 7. 8. 9. B. Mother Gross Income Other Income Subtotal Gross Income Federal Withholding (Claiming _____ exemptions) Federal Income Tax OASDHI Kansas Withholding Subtotal Deductions Net Income $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Self-Employed 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Father Mother Gross Income from self-employment Other Income Subtotal Gross Income Reasonable Business Expenses (Itemize on attached exhibit) Self-Employment Tax Estimated Tax Payments (Claim _____ exemptions) Federal Income Tax Kansas Withholding Subtotal Deductions Net Income (Line B.3. minus Line B.9.) Father $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Pay period: Mother Father American LegalNet, Inc. www.FormsWorkflow.com 9. The liquid assets of the parties are (do not list more than the last four digits of any account number shown): Item A. Amount Joint or Individual (Specify) Checking Accounts: $ $ B. Savings Accounts: $ $ C. D. Cash Mother Father Other $ $ $ $ 10. The monthly expenses of each party are: (Please indicate with an asterisk all figures which are estimates rather than actual figures taken from records.) A. Item 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Rent (if applicable)* Food Utilities: Trash Service Newspaper Telephone Gas Water Lights Other Insurance: Life Health Car House/Rental Other Medical and dental Prescriptions drugs Child care (work-related) Child care (non-work-related) Clothing School expenses Hair cuts and beauty Car repair Gas and oil Personal property tax Mother (Actual or Estimated) Father (Actual or Estimated) $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ American LegalNet, Inc. www.FormsWorkflow.com Mother (Actual or Estimated) Item 15. Father (Actual or Estimated) Miscellaneous (Specify) $ $ $ $ $ $ $ $ 16. $ $ $ $ $ $ $ $ $ $ Debt Payments (Specify) Total *Show house payments, mortgage payments, etc., in Section 10.B. B. Creditor Monthly payments to banks, loan companies or on credit accounts: (Indicate actual or estimated, use asterisk for secured.) DO NOT LIST ANY PAYMENTS INCLUDED IN PART 10.A ABOVE. When Incurred Amount of Payment Date of Last Payment Responsibility Mother Father Balance $ $ $ $ $ $ Subtotal of Payments Total $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ C. Total Living Expenses Mother (Actual or Estimated) 1. Total funds available to Mother and Father (from No. 8) 2. Total needed (from No. 10.A and B) 3. Net Balance 4. Projected child support Father (Actual or Estimated) $ $ $ $ $ $ $ $ American LegalNet, Inc. www.FormsWorkflow.com D. Payments or contributions received, or paid, for support of others. Specify source and amount. Source Mother (+/-) (+/-) (+/-) (+/-) 11. Father $ $ $ $ $ $ $ $ How much does the party who provides health care pay for family coverage? $ per . How much does it cost the provider to furnish health insurance only on the provider? $ per . FURNISH THE FOLLOWING INFORMATION IF APPLICABLE. 12. Income and financial resources of children. Income/Resources Amount $ $ $ $ 13. Child support adjustments requested. Mother Long Distance Visitation Costs Father Visitation Adjustments Income Tax Considerations Special Needs Agreement Past Minority $ $ $ $ $ $ $ $ $ $ $ $ Overall Financial Condition $ $ 14. All other personal property including retirement benefits (including but not limited to qualified plans such as profit-sharing, pension, IRA, 401[k], or other savings-type employee benefits, nonqualified plans, and deferred income plans), and ownership thereof (joint or individual), including policies of insurance, identified as to nature or description, ownership (joint or individual), and actual or estimated value. Do not list more than the last four (4) digits of any account number shown. Amount Joint or Individual (Specify) $ $ $ $ American LegalNet, Inc. www.FormsWorkflow.com THE FOLLOWING NEED NOT BE FURNISHED IN POST JUDGMENT PROCEDURES. 15. List real property identified as to description, ownership (joint or individual) and actual or estimated value. Property Description 16. Actual/Estimated Value Identify the property, if any, acquired by each of the parties prior to marriage or acquired during marriage by a will or inheritance. Property Description 17. Ownership Ownership Source of Ownership Actual/ Estimated Value List debt obligations, including maintenance, not listed in Section 10.A or 10.B above, identified as to name or names of obligor or obligors and obligees, balance due and rate at which payable; and, if secured, identify the encumbered property. Debt Obligation Obligor Obligee Balance Due Payment Rate Encumbered Property American LegalNet, Inc. www.FormsWorkflow.com 18. List health insurance coverage and the right, pursuant to ERISA §§ 601-608, 29 U.S.C. §§ 1161-1168 (1986), to continued coverage by the spouse who is not a member of the covered employee group. Health Insurance Yes COBRA Continuation No Unknown AFFIANT /s/ VERIFICATION State of , County of , I swear or affirm under penalty of perjury that this affidavit and attached schedules are true and complete. /s/ Subscribed and sworn this day of , 20 . /s/ Notary Public My Appointment Expires: American LegalNet, Inc. www.FormsWorkflow.com