DR-501 Page 1 of 7 Rev. 4/18 COURT OF COMMON PLEAS DOMESTIC RELATIONS DIVISION CLERMONT COUNTY, OHIO Case Number Plaintiff vs. Defendant Instructions : Check local court rules to determine when this form must be filed. This affidavit is used to make complete disclosure of income, expenses and money owed. It is used to determine child and spousal support amounts. Do not leave any category blank. Write 223none224 where appropriate. If you do not know exact figures for any item, give your best estimate, and put 223EST.224 If you need more space, add additional pages. AFFIDAVIT OF INCOME AND EXPENSES Affidavit of ( Print Your Name) SECTION I - INCOME Your Spouse222s Employed Yes No Yes No Employer Payroll address Payroll city, state, zip Scheduled paychecks per year 12 24 26 52 12 24 26 52 A. YEARLY INCOME, OVERTIME, COMMISSIONS AND BONUSES FOR PAST THREE YEARS Your Spouse222s Base yearly income $ 3 years ago 20 $ $ 2 years ago 20 $ $ Last year 20 $ Yearly overtime, commissions and/or bonuses $ 3 years ago 20 $ $ 2 years ago 20 $ $ Last year 20 $ American LegalNet, Inc. www.FormsWorkFlow.com DR-501 Page 2 of 7 Rev. 4/18 B. COMPUTATION OF CURRENT INCOME Your Information Spouse222s Information Base yearly income $ $ Average yearly overtime, commissions and/or bonuses over last 3 years (from part A) $ $ Unemployment compensation $ $ Disability benefits $ $ Workers222 Compensation Social Security Other: Retirement benefits $ $ Social Security Other: Spousal support received $ $ Interest and dividend income (source) $ $ Other income (type and source) $ $ TOTAL YEARLY INCOME $ $ Supplemental Security Income (SSI) or public assistance $ $ Court-ordered child support that you receive for minor and/or dependent child/ren not of the marriage or relationship $ $ American LegalNet, Inc. www.FormsWorkFlow.com DR-501 Page 3 of 7 Rev. 4/18 SECTION II 226 CHILDREN AND HOUSEHOLD RESIDENTS List the minor or dependent child/ren that you have with your spouse: Name Date of birth Living with In addition to the above child/ren, your household includes: adult/s other minor and/or dependent child /ren . SECTION III 226 EXPENSES List monthly expenses below for your present household. A. MONTHLY HOUSING EXPENSES Rent or first mortgage (including taxes and insurance) $ Real estate taxes (if not included above) $ Real estate/homeowner222s insurance (if not included above) $ Second mortgage/equity line of credit $ Utilities o Electric $ o Gas, fuel oil, propane $ o Water and sewer $ o Telephone $ o Cell Phone $ o Trash collection $ o Cable/satellite television $ o Internet $ Cleaning, maintenance, repair $ Lawn service, snow removal $ Other: $ $ TOTAL MONTHLY : $ American LegalNet, Inc. www.FormsWorkFlow.com DR-501 Page 4 of 7 Rev. 4/18 B. OTHER MONTHLY LIVING EXPENSES Food o Groceries (including food, paper, cleaning products, toiletries, other) $ o Restaurant $ Transportation o Vehicle loans, leases $ o Vehicle maintenance (oil, repair, license) $ o Gasoline $ o Parking, public transportation $ Clothing o Clothes (other than child/ren ) $ o Dry cleaning, laundry $ Personal grooming o Hair, nail care $ o Other $ Other $ TOTAL MONTHLY $ C. MONTHLY CHILD-RELATED EXPENSES For child/ren you have with your spouse only (not step-child/ren). Work/education - related child care $ Other child care $ Unusual parenting time travel $ Special and unusual needs of child/ren (not included elsewhere) $ Extraordinary obligations for minor/handicapped child/ren $ Clothing $ School supplies $ Child/ren allowances $ Extracurricular activities, lessons $ School lunches $ Other $ TOTAL MONTHLY $ American LegalNet, Inc. www.FormsWorkFlow.com DR-501 Page 5 of 7 Rev. 4/18 D. MONTHLY CHILD-RELATED EXPENSES For child/ren you have with someone other than your spouse. Work/education - related child care $ Other child care $ Unusual parenting time travel $ Special and unusual needs of child/ren (not included elsewhere) $ Extraordinary obligations for minor/handicapped child/ren $ Clothing $ School supplies $ Child/ren allowances $ Extracurricular activities, lessons $ School lunches $ Other $ TOTAL MONTHLY $ E. MONTHLY INSURANCE PREMIUMS Life $ Auto $ Health $ Disability $ Renters/personal property (if not included in part A above) $ Other $ TOTAL MONTHLY $ F. MONTHLY EDUCATION EXPENSES Tuition o Self $ o Child(ren) $ Books, fees, other $ College loan repayment $ Other $ $ TOTAL MONTHLY: $ American LegalNet, Inc. www.FormsWorkFlow.com DR-501 Page 6 of 7 Rev. 4/18 H. MONTHLY HEALTH CARE EXPENSES (not covered by insurance) Physicians $ Dentists $ Optometrists/opticians $ Prescriptions $ Other $ $ TOTAL MONTHLY: $ G. MISCELLANEOUS MONTHLY EXPENSES Child support you pay for child/ren you have with someone other than your spouse $ Spousal support paid to former spouse/s $ Subscriptions, books $ Entertainment $ Charitable contributions $ Memberships (associations, clubs) $ Travel, vacations $ Pets $ Gifts $ Bankruptcy payments $ Attorney fees $ Required deductions from wages (excluding taxes, Social Security and Medicare) Describe or specify: $ Additional taxes paid (not deducted from wages) (type) $ Other $ $ TOTAL MONTHLY: $ American LegalNet, Inc. www.FormsWorkFlow.com DR-501 Page 7 of 7 Rev. 4/18 I. MONTHLY INSTALLMENT PAYMENTS (Do not repeat expenses already listed elsewhere in this affidavit) Examples: car, credit card, rent-to-own, cash advance payments To whom paid Purpose Balance due Monthly payment $ $ $ $ $ $ $ $ $ $ $ $ TOTAL MONTHLY : $ GRAND TOTAL MONTHLY EXPENSES (Sum of A through H): $ OATH (Do not sign until notary is present.) I, (print name) , swear or affirm that I have read this document and, to the best of my knowledge and belief, the facts and information stated in this document are true, accurate and complete. I understand that if I do not tell the truth, I may be subject to penalties for perjury. Your S ignature Sworn before me and signed in my presence this day of , . Notary Public My C ommission E xpires: American LegalNet, Inc. www.FormsWorkFlow.com