IN THE COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS BUTLER COUNTY, OHIO Judge Sharon L. Kennedy Judge Eva D. Kessler DR 602A Rev. 8/05 _____________________________________ Plaintiff/1st Petitioner/Petitioner DOB ________________________________ Address ______________________________ ______________________________ Case No. ___________________ Affidavit of Income ______________________ V. (Name of Affiant) _____________________________________ Defendant/2nd Petitioner/Respondent DOB ________________________ Address Date of Marriage __________________ Date of Separation_________________ ______________________ _____________________________ Note: This affidavit must be completed and exchanged in accordance with Local Rules of Court in every action for divorce, dissolution, legal separation, annulment and post decree motion that concerns modification of support. You will be required to provide proof of income per local rule and O.R.C. 3121. You are under a continuing legal duty to file an updated version of this form if you learn of any additional information. If more space is needed, attach additional page(s). I. Income [As defined in O.R.C. 3119.01(C)]: A. Gross Yearly Income from Employment (If not known, please estimate. Put "EST" after each estimated figure.) Husband / Father Wife / Mother Gross Yearly Employment Income Employer Address of Employer City, State, Zip Check the number of Paychecks per year Year-to-date Gross Income 12 24 26 52 12 Through date of 24 26 52 Through date of Prior Year's Tax Refund American LegalNet, Inc. www.USCourtForms.com Initialed Income Affidavit Page 1 B. Annual Overtime, Commissions, Bonuses (If not known, please estimate. Put "EST" after each estimated figure.) Husband / Father Year 3 is Most Recent Year Base Income Wife / Mother Overtime, Commission, Bonuses Year 3 is Most Recent Year 20 Year 1 20 Year 2 20 Year 2 20 Year 3 20 Overtime, Commission, Bonuses Year 1 20 Base Income Year 3 Y-T-D This Year Through:_____ Y-T-D This Year Through: _______ C. Gross Self-Employment Income (If not known, please estimate. Put "EST" after each estimated figure.) Use Gross Annual Figures for Most Recent Full Year. See O.R.C. 3119.01(C) Husband / Father Wife / Mother Business Receipts Ordinary & Necessary Business Expenses Net Business Income D. Other Income All other income, actual or expected, including pension, social security, workers compensation, commissions, royalties, disability benefits, trust income, annuities, recurring capital gains, unemployment benefits, rents, expense-sharing, dividends, interest, AFDC, SSI, food stamps, spousal support received from a prior spouse, etc. (If not known, please estimate. Put "EST" after each estimated figure.) Husband / Father Per Year Wife / Mother Describe Per Year E. Total Annual Income Husband / Father Total gross annual income Total average gross monthly income Describe Wife / Mother Total gross annual income ÷ 12 = Total average gross monthly income American LegalNet, Inc. www.USCourtForms.com Initialed ÷ 12 = Income Affidavit Page 2 Less Less Average monthly deductions Total net monthly income Average monthly deductions = Total net monthly income = F. Benefits of Employment (Use of company car, country club memberships, stock options, etc.) Husband / Father Benefits Wife / Mother Values Benefits Values II. Information Required for Support Calculation: A. Minor or Dependent Children of this Marriage Child's Name Date of Birth Residing with Date of Birth Relationship B. Other Minor Children Living in My Household Child's Name C. Other Minor Children of Mine, Not Living in My Household Child's name Date of Birth Residing with OATH OF AFFIANT (print) hereby swear or affirm that the information set forth in this I, Affidavit of Income above is true, complete, and accurate. I understand that falsification of this document may result in a contempt of court finding against me which could result in a jail sentence and fine, and that falsification of this document may also subject me to criminal penalties for perjury (O.R.C. 2921.22). AFFIANT Sworn to and subscribed before me this Day of , . Notary Public American LegalNet, Inc. www.USCourtForms.com Initialed Income Affidavit Page 3