IN THE COURT OF COMMON PLEAS DOMESTIC RELATIONS DIVISION COLUMBIANA COUNTY, OHIO CASE NO.: ________________________ __________________________________ __________________________________ ___________________________________ SSN: ______________________________ D.O.B.: __________________________ EMPLOYER: _____________________ Plaintiff -VS___________________________________ ___________________________________ ___________________________________ SSN: ______________________________ D.O.B.: ____________________________ EMPLOYER: ________________________ Defendant Now comes ___________________________________, the Affiant, being first duly sworn, and says that the following questions are true and accurate to the best of the Affiant's belief and knowledge: DEPENDENTS Identify all persons whom you are legally obligated to support and identify whether you pay or received support for these dependents: Born to this Marriage? Name and Date of Birth Current Place of Residence Relationship Age Amount of Support Ordered Date & Place of Marriage: _____________ ___________________________________ FINANCIAL AFFIDAVIT Judge: ______________________ PERSONAL INFORMATION HUSBAND Age Education, Occupation, and Training Present Health & Well Being Previous Number of Marriages, Children WIFE American LegalNet, Inc. www.FormsWorkFlow.com EMPLOYMENT AND MEDICAL INSURANCE Answer the following questions about your and your spouse's employment and insurance from all sources, including health care insurance Husband Employer: Wife Address: Telephone: Medical Insurance: Address: Insurance ID Number including Subscriber's ID, Group and Policy No Children Covered (Y/N) Out-of-pocket cost to Husb. Or Wife? Names of Additional Employers within the last 12 months: PENSION AND OTHER RETIREMENT PLANS Husband Name of Plane Type of Plan Eligible Age and Starting Year Future Monthly Payment at Retirement Date Wife WORKERS COMPENSATION, DISABILITY, OR OTHER BENEFITS Report all workers compensation, disability, social security, pension, retirement, or other benefit received by you or your spouse: Husband Source or Name of Benefit (WCSS, PERS, ADC, GR, etc.) Claim Number type (TT, PT, Ret, ADC, GR, etc.) Amount or Rate and its frequency Current Status and/or Expiration Date: Wife American LegalNet, Inc. www.FormsWorkFlow.com SEPARATE PROPERTY Section 3105.18(A)(6)(a) List all real and personal property and any interest in real or personal property acquired (I) by inheritance["I"], (ii) before the marriage ["B"], (iii) passive income and appreciation from separate property during the marriage ["PAS"], (iv) after a decree of legal separation ["LS"], (v) by exclusion by antenuptial agreement ["AN"], (vi) personal injury compensation ["PI"] except loss of marital earnings and expenses paid from marital assets, (vii) gifts solely to one spouse ["G"] Category Description Particulars re date acquired, tracing, and dispositions leading to ownership of the property FMV Debt INHERITANCES PROPERTY OWNED BEFORE MARRIAGE PASSIVE INCOME AND APPRECIATION FROM SEPARATE PROPERTY PROPERTY ACQUIRED AFTER A DECREE OF LEGAL SEPARATION EXCLUDED BY ANTENUPTUAL AGREEMENT PERSONAL INJURY COMPENSATION EXCEPT LOSS OF MARITAL EARNINGS, ETC. GIFTS SOLELY TO ONE SPOUSE American LegalNet, Inc. www.FormsWorkFlow.com MARITAL ASSETS List and describe all marital property. Abbreviations may be used to answer Possession, Owner, and Source questions, ie. "H" for husband "W" for wife, "J" for joint. Use the second column to particularly describe the property. Use extra pages if necessary and give a reference to the schedule or exhibit that contains the additional information. Category Description/Name Possession FUNDS ON DEPOSIT Owner Source FMV Debt Equi y Monthly Payment REAL ESTATE FURN HOUSE GOODS MOTOR VEHICLES TOOLS STOCKS & SECURITIES INSURANCE (identify + amount of Cash Value) PENSIONS & RETIREMENT ACCTS. PERSONAL EFFECTS OTHER, including jewelry, art, boats, notes, accts. Rec, etc. SUBTOTAL ASSET & ENCUMBRANCES OTHER DEBTS THAT WERE NOT INCLUDED ABOVE Department Stores Credit Card (V, MC, AX, etc.) Loans Use supplemental sheet if necessary "" "" "" "" "" "" TOTALS American LegalNet, Inc. www.FormsWorkFlow.com SCHEDULE OF DEPARTMENT STORE CHARGE ACCOUNTS, CREDIT CARDS, UNSECURED LOANS AND OTHER DEBTS (Pass subtotals of each category to Marital Worksheet under the appropriate category Type Name of Creditor Debt Monthly Payment DEPARTMENT STORE CHARGE ACCOUNTS SUBTOTAL, DEPARTMENT STORE ACCOUNTS CREDIT CARDS SUBTOTAL, CREDIT CARDS UNSECURED LOANS SUBTOTAL, UNSECURED LOANS OTHER DEBTS SUBTOTAL, OTHER DEBTS American LegalNet, Inc. www.FormsWorkFlow.com INCOME HISTORY | Three Years Ago Husband Two Years Ago One Year Ago Current Year To Date | Three Years Ago Wife Two Years Ago One Year Ago Current Year To Date Wages, Commissions, Salaries, other than overtime and bonuses Overtime and Bonuses Other Income Totals CURRENT INCOME State the sources and amounts of all income for you and your spouse. Use extra pages to itemize or explain. [Identify Reporting Period, i.e. Per year, Per Month, Every 2 Wks, etc.] Husband WAGES Gross Wages Every ( ) Wife Federal Income Tax Social Security (FICA) State Income Tax Local Tax Union dues Medical Insurance Spousal or Child Support Orders Other: bonds, credit union, savings, Keogh SUBTOTAL DEDUCTIONS INTEREST INCOME DIVIDENDS ANNUITIES RENTALS, TRUSTS, PARTNERSHIPS, ESTATES, SCORPS, OR BUSINESS. INCLUDE (ADD BACK) DEPRECIATION EXPENSES. IN-KIND BENEFITS Type: _____________________________ OTHER INCOME Type: _____________________________ GRAND TOTAL, GROSS INCOME GRAND TOTAL, NET AFTER WAGE DEDUCTIONS American LegalNet, Inc. www.FormsWorkFlow.com AVERAGE REGULAR MONTHLY EXPENSES HUSBAND FOOD, including Milk & School Lunches HOUSING: Rent/Mortgage R/E Taxes Insurance Maintenance & Repairs UTILITIES: Electric Heating Fuel Water/Sewer Telephone Cable TV Trash Service MEDICAL: Insurance (not in wage deduction) Uninsured Med & Drugs CLOTHING & SHOES LAUNDRY & HOUSEHOLD: AUTO: Loan Payments Insurance Gas, Oil, Repairs Other Transportation INSURANCE (Other than R/E, Auto, Med) Life Disability Medical(not deducted from Wages) Other: ____________________________ RECREATION/ENTERTAINMENT PERSONAL GROOMING DAY CARE, BABY-SITTERS, & OTHER CHILD CARE DEBT PAYMENT, except R/E, Auto, or other from above OTHER: Specify. Use Extra Paper if Needed. TOTAL EXPENSES: WIFE The undersigned, ____________________________________, affairs that th