Affidavit Of Income And Expenses Form. This is a Ohio form and can be use in Clermont County (Court Of Common Pleas).
Tags: Affidavit Of Income And Expenses, DR-501, Ohio County (Court Of Common Pleas), Clermont
COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS CLERMONT COUNTY, OHIO Case No. ___________________________ _________________________ Plaintiff/Petitioner Judge __________________________ v./and Magistrate ________________________ _________________________ Defendant/Petitioner Instructions: 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 “none” where appropriate. If you do not know exact figures for any item, give your best estimate, and put “EST”. This affidavit may be used by the Court in issuing temporary support orders under Rule 75 of the Ohio Rules of Civil Procedure. However, this affidavit may NOT be considered as evidence at any future hearing unless offered and admitted under the Ohio Rules of Evidence. You must provide verification of your income and the income of the opposing party or state the reason(s) why you cannot provide verification. If verification of income(s) is not provided, a support order may not issue. AFFIDAVIT OF INCOME AND EXPENSES Affidavit of ______________________________ (Print Your Name) Date of marriage _____________ Date of separation _____________ SECTION I – INCOME Husband Employed Employer Payroll address Payroll city, state, zip Scheduled paychecks per year Wife Yes 12 No 24 26 Yes 52 12 No 24 26 52 A. YEARLY INCOME, OVERTIME, COMMISSIONS AND BONUSES FOR PAST THREE YEARS Husband Wife Base yearly income $ $ $ 3 years ago 2 years ago Last year 20____ 20____ 20____ $ $ $ Yearly overtime, commissions and/or bonuses $ $ $ 3 years ago 2 years ago Last year 20____ 20____ 20____ $ $ $ Page 1 of 8 American LegalNet, Inc. www.FormsWorkFlow.com B. COMPUTATION OF CURRENT INCOME Husband Base yearly income $ Average yearly overtime, commissions and/or bonuses over last 3 years (from part A) $ Unemployment compensation $ Disability benefits – calculate yearly amount Workers’ Compensation Social Security Other:________________________ Wife $ Retirement benefits – calculate yearly amount Social Security Other:_______________________ $ Spousal support received $ Interest and dividend income (source) – per year _______________________________ _______________________________ $ Other income (type and source) – per year _______________________________ _______________________________ $ TOTAL YEARLY INCOME $ Supplemental Security Income – per year (SSI) or public assistance $ Court-ordered child support that you receive for minor and/or dependent child(ren) not of the marriage or relationship $ Page 2 of 8 American LegalNet, Inc. www.FormsWorkFlow.com SECTION II – CHILDREN AND HOUSEHOLD RESIDENTS Minor and/or dependent child(ren) who are adopted or born of this marriage or relationship: Name Date of birth Living with In addition to the above children there is/are in your household: ________ adult(s) ________ other minor and/or dependent child(ren). SECTION III – 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/homeowner’s 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 Trash collection $ o Cable/satellite television $ Cleaning, maintenance, repair $ Lawn service, snow removal $ Other:____________________________________________ $ Other:____________________________________________ $ TOTAL MONTHLY: $ Page 3 of 8 American LegalNet, Inc. www.FormsWorkFlow.com 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 children’s) $ o Dry cleaning, laundry $ Personal grooming o Hair, nail care $ o Other _______________________________________ $ Cell phone $ Internet (if not included elsewhere $ Other ______________________________________________ $ TOTAL MONTHLY $ C. MONTHLY CHILD-RELATED EXPENSES (for children of the marriage or relationship) Work/education-related child care $ Other child care $ Unusual parenting time Travel $ Special and unusual needs of child(ren) (not included elsewhere) $ Clothing $ School supplies $ Child(ren)’s allowances $ Extracurricular activities, lessons $ School lunches – (cost for school year, divided by 12 months) $ Other ______________________________________________ $ TOTAL MONTHLY $ Page 4 of 8 American LegalNet, Inc. www.FormsWorkFlow.com D. INSURANCE PREMIUMS Life $ Auto $ Health $ Disability $ Renters/personal property (if not included in Part A above) $ Other _____________________________________________ $ TOTAL MONTHLY $ E. MONTHLY EDUCATION EXPENSES Tuition o Self $ o Child(ren) $ Books, fees, other $ College loan repayment $ Other ______________________________________________ ______________________________________________ $ TOTAL MONTHLY $ F. MONTHLY HEALTH CARE EXPENSES (not covered by insurance) Physicians $ Dentists $ Optometrists/opticians $ Prescriptions $ Other _______________________________________________ _______________________________________________ $ TOTAL MONTHLY $ G. MISCELLANEOUS MONTHLY EXPENSES Extraordinary obligations for other minor/handicapped child(ren) (not stepchildren) Child support for children who were not born of this marriage or relationship and were not adopted of this marriage $ $ Spousal support paid to former spouse(s) $ Subscriptions, books $ Entertainment $ Page 5 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Charitable contributions $ Memberships (associations, clubs) $ Travel, vacations $ Pets $ Gifts $ Bankruptcy payments $ Attorney fees $ Required deductions from wages (excluding taxes, Social Security and Medicare) (type) ___________________________________ $ Additional taxes paid (not deducted from wages)(type) ____________________________________________________ $ Other _______________________________________________ _______________________________________________ $ TOTAL MONTHLY H. MONTHLY INSTALLMENT PAYMENTS (Do not repeat expenses already listed.) 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): S $ ________________ Page 6 of 8 American LegalNet, Inc. www.FormsWorkFlow.com 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 signature Sworn before me and signed in my presence this ____ day of _______________________, _______ ___________________________________ Notary Public My commission expires: ___________________________________ New 7/1/10 Form DR-501 Page 7 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Page 8 of 8 American LegalNet, Inc. www.FormsWorkFlow.com