COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS CLERMONT COUNTY, OHIO ________________________ Plaintiff/Petitioner ________________________ Street ________________________ City ST Zip CASE NO. _____________________ VS. ________________________ Defendant/Respondent ________________________ Street ________________________ City ST Zip AFFIDAVIT OF INCOME, EXPENSES, AND FINANCIAL DISCLOSURE SETS NO. _____________________ JUDGE MICHAEL J. VORIS Magistrate _____________________ Notes: This affidavit must be filed and served with the first pleading filed by each party in every action for divorce, dissolution, legal separation, and annulment. In those actions, the Assets/Debts/Separate Property Statement form must be attached to this affidavit. This affidavit must also be filed and served with every post-decree motion that concerns a modification of support. You will be required to provide proof of income per local rule and O.R.C. 3119.05(A). If more space is needed, attach additional page(s). I. Information Required for Support Calculation: A. Date of Marriage Date of Separation Date of Divorce Decree (If Post-Decree Case) B. Minor or Dependent Children of this Marriage (include adopted children and any child of the parties who is over 18 and handicapped) Child’s name Date of Birth Residing with C. Other Minor Children Living in My Household Child’s name Date of Birth Residing with American LegalNet, Inc. www.FormsWorkflow.com D. Other Minor Children of Mine, Not Living in My Household Child’s name Date of Birth Residing with II. Income [As defined in O.R.C. 3119.01(B)(5)]: A. Gross Yearly Income from Employment (If not known, please estimate. Put “EST” after each estimate figure.) Husband/Father Gross Yearly Employer Payroll Address City, State, Zip Check the number of paychecks per year Wife/Mother □12 □24 □26 □52 □12 □24 □26 □52 through date of Year-to-date Gross income through date of $ Prior Year’s Tax Refund $ $ $ B. 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. 3113.215(A) Business Receipts Ordinary & Necessary Business Expenses Net Business Income Husband/Father $ Wife/Mother $ $ $ $ $ C. Other Income All other income, actual or expected, including pension, social security, workers compensation, commissions, royalties, disability benefits, trust income, annuities, reoccurring 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.) Per Year $ $ Husband/Father Describe Per Year $ $ Wife/Mother Describe American LegalNet, Inc. www.FormsWorkflow.com D. Annual Overtime, Commissions, Bonuses (If not known, please estimate. Put “EST” after each estimated figure.) Year 3 is Most Recent Year 20__ Year 1 20__ Year 2 20__ Year 3 YTD This Year Through: ______ HUSBAND/FATHER Base Income Overtime, Commission, Bonuses $ $ $ $ $ $ $ $ Year 3 is Most Recent Year 20__ Year 1 WIFE/MOTHER Base Income $ $ $ $ $ 20__ Year 2 20__ Year 3 YTD This Year Through: ______ $ Overtime, Commission, Bonuses $ $ III. Child Support Guideline Adjustment: Husband/Father (All Figures Per Year) Wife/Mother (All Figures Per Year) Court Ordered Child Support You Pay for Other Child(ren) in Another Case $ $ Court Ordered Spousal Support You Pay to a Former Spouse Number of Your Other Dependent Child(ren) Living with You From a Previous Marriage $ $ Court Ordered Child Support You Receive for the Dependent Child(ren) You Indicated on line Above $ $ Child Care Expenses You Pay for Child(ren) of this Marriage (Employment or Educational-Related) $ $ Local Income Taxes Paid or Rate of Tax where you Live or Work Self-Employment Tax (5.6% of A.G.I.) $ $ $ Health Insurance Premium for Children (Family Plan Cost Less Individual Plan Cost) $ $ $ $ For Post Decree Modifications Only Current Spouse’s Gross Income or % $ or % Number of Your Other Dependent Child(ren) Living with You From a Present Marriage [Excluding unadopted step child(ren)] American LegalNet, Inc. www.FormsWorkflow.com IV. Affiant’s Monthly Living Expenses: List your ACTUAL expenses for your present household in the first column. Give estimated expenses if you don’t have exact figures. If you expect changes soon, list your ANTICIPATED expenses in your household after the divorce case in the second column. Explain why you expect your expenses to change. Also, if you are living with your parents or someone is helping you with your living expenses, please explain. My Average Monthly Expenses A. Housing Anticipated Future Monthly Expenses in My Household The reason I expect my household living expenses to change soon is: Actual There are now ___ Adults and ____ children living in my present household. Actual Monthly Expenses in My Present Household I am assisted with my living expenses by: Anticipated Rent or First Mortgage $ Real Estate Taxes (if not included above) $ Real Estate Insurance (if not included above) $ Second Mortgage, if any $ UTILITIES: Electric (level billing or avg/month) $ Gas (if billed separately) $ Fuel Oil/Propane $ Water & Sewer $ Telephone (basic monthly charge) $ Water Softener $ Trash Collection $ Telephone (average long distance $ Cable Television $ Home Cleaning, Maintenance, Repair $ Lawn Service, Snow Removal $ Housing Total Other: $ $ (A) (A) American LegalNet, Inc. www.FormsWorkflow.com B. Other Necessary Living Expenses FOOD, ETC.: Grocery (include food, paper & cleaning products, toiletries, etc.) Restaurant TRANSPORTATION, ETC.: Car Loan or Lease Actual Anticipated $ $ $ Gasoline $ Car Maintenance & Repair $ Parking, Public Transit $ CLOTHING, ETC.: Clothes $ Dry Cleaning, Laundry $ Personal Grooming $ Other $ Other: $ Other Necessities Total $ C. Child-Related Expenses (B) Actual Child Care, Work-or Educational-Related $ School Lunches $ Children’s Allowances $ Extra-Curricular Activities $ Other: $ Child-Related Expenses Total $ Anticipated $ Clothing (B) (C) (C) American LegalNet, Inc. www.FormsWorkflow.com Actual D. Educational Expenses for: You Tuition $ Activities $ College Loan Repayment $ Other: Child(ren) $ Tutor You $ Fees Child(ren) $ Books Anticipated $ Education Total $ E. Medical Expenses Out of Pocket (D) You Doctor $ Orthodontist $ Prescriptions $ Other: Child(ren) $ Optical You $ Dentist Child(ren) (D) $ Medical Total $ F. Insurance (E) Actual Life $ Health $ Disability $ COBRA Insurance Coverage $ Personal Property $ Other: Anticipated $ Auto (E) $ Insurance Total $ (F) (F) American LegalNet, Inc. www.FormsWorkflow.com G. Enrichment (Your expenses. Put child(ren)’s expenses under C or D, above) Actual Entertainment $ Lessons $ Books, Newspapers, Magazines $ Sports $ Clubs $ Hobbies $ Donations $ Gifts $ Vacation $ Other: Anticipated $ Enrichment Total $ H. Miscellaneous Expenses (G) Actual 1. $ 3. Anticipated $ 2. (G) $ Miscellaneous Expenses Total $ (H) (H) Grand Total of Monthly Expenses (Sum of A – H in each column) $ OATH OF AFFIANT I hereby swear or affirm that the information set forth in this Affidavit of Income, Expenses, and Financial Disclosure 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. 2921.11). ______________________________________ AFFIANT Sworn to and subscribed before me this __________ day of __________________, __________. ___________________________________ Notary Public Rev. 2/09 Form DR 509-2/ p. 1-7 American LegalNet, Inc. www.FormsWorkflow.com