DR0706107 Post Decree Income and Expense Statement.doc COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS CUYAHOGA COUNTY, OHIO _________________________________________ Plaintiff : _________________________________________ Address : _________________________________________ City, State, Zip Code : _________________________________________ Day Time Telephone Number : _________________________________________ Attorney : _________________________________________ Attorney Address : _________________________________________ Attorney Telephone : Vs Case Number: ___________________________________ Judge: ___________________________________ : _________________________________________ Defendant : _________________________________________ Address : _________________________________________ City, State, Zip Code : _________________________________________ Day Time Telephone : _________________________________________ Attorney : _________________________________________ Attorney Address : _________________________________________ Attorney Telephone INCOME AND EXPENSE STATEMENT WITH AFFIDAVIT (Post-Decree) of: : ______________________________ (Your name) Date of Divorce or Last Support Order: _______________________________ NOTE: In accordance with Local Rule 19 of this Court, this Statement must be completed by each party prior to the time of hearing on any motion to modify child support or spousal support. You will be required to provide proof of income per Rule 19 and Ohio Revised Code §3119.05(A). You are under a continuing legal duty to file an updated version of this form if you learn of any additional information. ATTACH ADDITIONAL PAGES IF MORE SPACE IS NEEDED Initial: ________ Page 1 of 5 American LegalNet, Inc. www.FormsWorkflow.com I. Information Required for Support Calculation: Minor or Dependent Children of this Marriage A. (Include adopted children and any child of the parties who is over 18 and still attending high school or is mentally or physically disabled) Child’s Name Date of Birth Age Residing with ARE THERE ANY OTHER SUPPORT ORDERS ESTABLISHED FOR THESE CHILDREN? YES NO IF YES, ATTACH COPY OF ORDER AND PROVIDE THE FOLLOWING INFORMATION: DATE OF ORDER:_________ AMOUNT: $____________ CASE NUMBER: ________________ B. SETS NUMBER: ___________________ COURT (or agency) NAME: ______________________________ Other Minor Children Living in My Household. Child’s Name Relationship to You Date of Birth Age Court Ordered Support Received $ $ $ Other Minor Children of Mine, NOT Living in My Household. C. Child’s Name Residing with Date of Birth Age Court Ordered Support Paid $ $ $ II. Child Support Guideline Adjustment: Husband/Father (all figures per year) Wife/Mother (all figures per year) Total court ordered child support you pay for other children Total court ordered spousal support you pay to former spouse(s) Number of your other dependent children living with you from another marriage or relationship Court ordered child support you receive for the dependent child(ren) you indicated on line above Childcare 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 minus individual plan cost) $ $ $ $ % $ % III. Annual Income [as defined in Ohio Revised Code §3119.01(B)(5)]: Gross Annual Income from Employment (If not known, please estimate and write “EST” after each estimated figure.) Gross Annual Husband/Father Wife/Mother Employment Income ► $ Salary Wages $ Salary Wages Name(s) of Employer(s) Payroll Address(es) City, State, Zip Check the number of 12 24 26 52 12 24 26 52 paychecks per year Through date of: Through date of: Year-to-date Gross Income $ $ Prior Year’s Tax Refund $ $ Benefits from Employment A. (Company Car, Club Memberships, Stock Options, etc.) 1. 2. 3. Total Annual Value of Benefits: $ $ $ $ $ $ $ $ Initial: ________ Page 2 of 5 American LegalNet, Inc. www.FormsWorkflow.com B. Annual Overtime, Commissions and Bonuses (If not known, please estimate and write “EST” after each estimated figure.) Husband/Father Base Income Wife/Mother Overtime, Commissions & Bonuses Base Income Overtime, Commissions & Bonuses LAST YEAR: $ $ $ $ 2 YEARS AGO: $ $ $ $ $ $ $ $ $ $ $ $ 3 YEARS AGO: THIS YEAR THROUGH ► Month Day Year C. Gross Annual Self-Employment Income (If not known, please estimate and write “EST” after each estimated figure.) Use gross annual figures for most recent full year. See Ohio Revised Code §3119.01(C)(13) Gross Annual Business Receipts $ Company Name Ordinary & Necessary Business Expenses - $ Company Address Net Annual Business Income =$ Nature of Business: D. Other Annual Income: Other income includes commissions (other than from employment), royalties, tips, rents, dividends, severance pay, interest, trust income, annuities, social security benefits (including retirement, disability and survivor benefits that are not need based), workers’ compensation, unemployment insurance, spousal support actually received, recurring capital gains, etc. Also include military pay (including base pay, BAQ, BAS, specialty pay, variable housing allowance, training pay, combat pay, hazardous duty pay, etc). Need Based Assistance includes benefits received from a government-administered means-tested program such as Ohio works first, food stamps, SSI, disability financial assistance, etc. For complete definition of income see Ohio Revised Code Section 3119.01(C)(7). If exact amounts are not known, please estimate and write “EST” after each estimated figure. If more space is needed, attach extra pages. See additional pages: YES Husband/Father Other Income (Describe) Need Based Assistance Wife/Mother Other Income (Describe) Need Based Assistance $ $ $ $ $ $ $ $ $ $ $ $ $ Total Other Income E. $ $ Total Need Based Assistance $ $ Total Other Income $ $ Total Need Based Assistance $ Available Monthly Income Husband/Father Average Monthly Deductions Total Gross Fed/State/Local Annual Income $ Taxes Social Security Medicare Health Insurance $ Union Dues $ Pensions $ IRAs/401(k)s $ Support Orders $ Other: Total Average Deductions $ Wife/Mother Average Monthly Deductions Total Gross Fed/State/Local Annual Income $ Total Average Gross Monthly Income Divide Gross Annual By 12 $ Taxes Social Security Medicare Health Insurance Average Monthly Deductions Minus Union Dues $ $ Pensions $ Available Monthly Income Equals IRAs/401(k)s $ $ Support Orders $ $ Other: $ $ Total Average Deductions $ $ $ $ $ Total Average Gross Monthly Income Divide Gross Annual By 12 Average Monthly Deductions Minus Available Monthly Income Equals $ $ $ IV. Affiant’s Monthly Living Expenses: On pages 4 and 5 please list the ACTUAL expenses for your present household. Give estimated expenses if you do not have exact figures, and check the appropriate box if you give an estimated expense. Initial: ________ Page 3 of 5 American LegalNet, Inc. www.FormsWorkflow.com A. MONTHLY HOUSING EXPENSES RENT OR FIRST MORTGAGE (circle one) REAL ESTATE TAXES (if not included above) REAL ESTATE/HOMEOWNERS INSURANCE (if not included above) SECOND MORTGAGE or EQUITY LINE, if any UTILITIES: • Electric (level billing or average/month) Check box to right of each ESTIMATED expense Work/Educational Related Childcare $ $ Clothing $ $ School Supplies $ $ Children’s Allowances $ Extracurricular Activities, Lessons $ School Lunches Other: $ $ $ • Fuel Oil/Propane $ • Water and Sewer • Telephone (basic monthly charge & average long distance) $ $ TOTAL CHILD RELATED EXPENSES (C) D. MONTHLY INSURANCE PREMIUMS $ $ Check box to right of each ESTIMATED expense $ $ $ $ Renters/Personal Property Other (specify): $ $ Disability $ $ Health $ • Cleaning Service • Maintenance and home repairs Expenses LAWN SERVICE AND SNOW REMOVAL OTHER (specify): Life Auto • Cable Television CLEANING, MAINTENANCE, REPAIR FOOD, ETC.: • Groceries (include food, paper and cleaning products, toiletries, etc.) Check box to right of each ESTIMATED expense $ • Gas (if billed separately) TOTAL HOUSING (A) B. OTHER MONTHLY LIVING EXPENSES C. MONTHLY CHILD RELATED EXPENSES $ $ $ Check box to right of each ESTIMATED expense TOTAL INSURANCE PREMIUMS (D) $ Check box to right of each E. MONTHLY ESTIMATED expense EDUCATIONAL EXPENSES Description You Children $ Tuition $ $ $ Books, Fees, etc. $ $ $ $ College Loan Repayment Other: $ • Vehicle Loans and/or Leases $ $ • Vehicle Maintenance $ Total Education Expenses for Each Column $ $ • Gasoline $ TOTAL EDUCATION (E) (Add Both Columns) F. MONTHLY HEALTH CARE EXPENSES (Not covered by insurance) Description • Restaurant TRANSPORTATION, ETC. • Parking, Public Transportation CLOTHING, ETC. • Clothes (other than for children) • Dry Cleaning, Laundry PERSONAL GROOMING $ $ $ You Children $ $ $ $ Prescriptions Other (specify): $ $ $ $ $ Optometrists/Opticians $ $ Dentists $ $ $ $ Total Health Care Expenses for Each Column. $ TOTAL OTHER LIVING EXPENSES (B) Check box to right of each ESTIMATED expense Physicians $ CELL PHONE OTHER (Specify): $ TOTAL HEALTH CARE EXPENSES (F) (Add Both Columns) $ Initial: ________ $ Page 4 of 5 American LegalNet, Inc. www.FormsWorkflow.com G. MISCELLANEOUS MONTHLY EXPENSES (Your Expenses Only) H . MONTHLY DEBT PAYMENTS NOT PREVIOUSLY LISTED Check box to right of each ESTIMATED expense Include children’s expenses in section C or E on page 4 Last 4 digits of account # Check box to right of each ESTIMATED expense Identify by Creditor Entertainment $ $ Lessons, Health Clubs, Hobbies, Etc. Books, Newspapers, Magazines and Other Subscriptions $ $ $ $ Donations $ $ Gifts $ $ Vacations Other (specify): $ $ $ $ $ $ $ $ $ $ $ $ TOTAL MISCELLANEOUS (G) $ $ There are ________ adults and ________ children now living with me. $ I am assisted in my living expenses by: $ ______________________________________________ $ $ Amount of Contribution per Month: $__________________ DO NOT INCLUDE NEED BASED PUBLIC ASSISTANCE GRAND TOTAL OF MONTHLY EXPENSES TOTAL DEBT PAYMENTS (H) (SUM OF A thru H) It is very important that you add each section and place a total in this box ► $ $ V. Bankruptcy: Filed by Date of Filing Case Number Date of discharge or relief from stay Type of case Current monthly payments (Ch. 7, 11, 12, 13) $ $ OATH OF AFFIANT I, (print name) __________________________________, hereby swear or affirm that the information set forth in this Affidavit 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 (Ohio Revised Code §2921.11). ___________________________________________ Affiant Sworn to and subscribed before me this ________ day of ________________________, 20________. ___________________________________________ Notary Public Initial: ________ Page 5 of 5 American LegalNet, Inc. www.FormsWorkflow.com