COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS CUYAHOGA COUNTY, OHIO _________________________________________ Plaintiff : _________________________________________ Address : _________________________________________ City, State, Zip Code : Marital Residence: No : _________________________________________ Attorney Address : ___________________________________ : _________________________________________ Attorney Telephone Judge: : _________________________________________ Attorney ___________________________________ : _________________________________________ Day Time Telephone Number Case Number: Yes PRE-TRIAL STATEMENT WITH AFFIDAVIT OF PROPERTY, INCOME & EXPENSES vs. : _________________________________________ Defendant _________________________________ (Your Name) _________________________________________ Address : _________________________________________ City, State, Zip Code : Marital Residence: Yes WIFE HUSBAND No : _________________________________________ Day Time Telephone Number : _________________________________________ Attorney : _________________________________________ Attorney Telephone ____________________________ : _________________________________________ Attorney Address Date of Marriage: : Date of Separation ____________________________ THIS STATEMENT MUST BE FILED WITH THE COURT 7 DAYS PRIOR TO THE PRE-TRIAL CONFERENCE, IF ONE IS HELD OR IF NO PRE-TRIAL CONFERENCE IS HELD, THEN NO LATER THAN 14 DAYS PRIOR TO THE TRIAL DATE OR 3 DAYS AFTER RECEIPT OF NOTICE OF THE TRIAL DATE, WHICHEVER IS LATER, AND IN ACCORDANCE WITH LOCAL RULE 12 OF THIS COURT. A TIME-STAMPED COPY OF THIS STATEMENT SHALL ALSO BE DELIVERED TO THE ASSIGNED JUDGE’S SCHEDULER ON THE DATE OF FILING. BRING TO THE PRE-TRIAL CONFERENCE ALL DOCUMENTS AND OTHER SUPPORTING INFORMATION NECESSARY TO VERIFY OR EXPLAIN THE STATEMENTS MADE IN THIS PRE-TRIAL STATEMENT, INCLUDING, BUT NOT LIMITED TO, TAX RETURNS, PAY STUBS, CHECKBOOKS, DAY CARE RECEIPTS, CANCELLED CHECKS, INSURANCE CARDS, CERTIFICATES AND POLICIES. FAILURE BY EITHER PARTY TO COMPLETE, FILE AND PRESENT THIS FORM AS REQUIRED WILL SUBJECT THAT PARTY AND COUNSEL TO THE SANCTIONS PROVIDED IN DDR RULE 11(C)(2). ANY FALSE STATEMENT MADE HEREON MAY SUBJECT YOU TO CRIMINAL PENALTIES FOR PERJURY, AND MAY BE CONSIDERED A FRAUD UPON THE COURT. IF YOU FAIL TO DISCLOSE ANY ASSET, DEBT, INCOME OR EXPENSE, THE COURT MAY COMPENSATE YOUR SPOUSE WITH UP TO THREE (3) TIMES THE VALUE OF THE UNDISCLOSED ITEM(S), PER ORC 3105.171(E)(5). PLEASE USE THE YELLOW FORM FOR THE WIFE AND THE BLUE FORM FOR THE HUSBAND. DRPTS Revised 7/10 Initial: ________ Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com I. PROPERTY List ALL OF YOUR PROPERTY AND DEBTS, those of your spouse, and joint property and debts. Do not leave any category blank. For each item, if none, write “NONE.” If you do not know exact figures for any item, give your best estimate and write “EST.” A. Real estate interests: PLEASE STATE WHETHER ANY LEGAL ACTIONS ARE PENDING (i.e. FORECLOSURES, ETC.) If more space is needed, attach extra pages. Address (Check box if legal action is pending) A. Titled to Husband, Wife or Joint (Check box) H W Joint Present Fair Market Value YES See additional pages: Names & Addresses of Mortgage/Lien Holders Mortgage/Lien Balance Due Monthly Mortgage/Lien Payments W Joint $ $ $ $ $ H $ $ B. $ $ $ B. Other assets: PLEASE STATE WHETHER ANY LEGAL ACTIONS ARE PENDING. If more space is needed, attach extra pages. Category Include automobiles, trucks, motorcycles, boats, motor homes, etc. Identify year, make and name of Lien Holder YES Balance on Liens/Loans (if any) Monthly Payment on Liens/Loans In Possession of H or W Check box if subject of pending legal action. A. Vehicles Description See additional pages: Titled to: Present Fair (H, W or Market Value Joint) $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Check box if subject of pending legal action. Include checking, savings CDs, POD accounts, money market accounts, etc. Check box if subject of pending legal action. Identify each plan, including profit-sharing, IRAs, 401(k)s, etc. Identify name of company, type of shares, and number of shares. Check box if subject of pending legal action. D. Publicly Held Stocks, Bonds, Securities & Mutual Funds $ $ C. Pensions & Retirement Plans $ $ B. Financial Accounts $ DRPTS Revised 7/10 Initial: ________ Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com $ $ $ $ $ $ $ $ $ $ Specify the amount of any cash surrender value. $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Check box if subject of pending legal action. Identify business, type of ownership and percentage of stock Check box if subject of pending legal action. Identify policy, beneficiary and whether a term life or whole life policy Check box if subject of pending legal action. Give location and describe contents Include collections, rare books, stamps, guns, antiques, art objects, computers machinery, personal injury/workers compensation claims, promissory notes, loans to others, tax refunds due, interests in estates or trusts, franchises, copyrights, etc. Check box if subject of pending legal action. I. Furniture and Appliances $ $ H. Miscellaneous Assets $ $ G. Safe Deposit box(es) Monthly payment on Liens/Loans $ F. Life insurance Titled to: (H, W or Joint) Balance on Liens/Loans (if any) $ E. Closely Held Business Interests Description Present Fair Market Value $ Category Attach detailed inventory if more space is needed See attached inventory In your possession In spouse’s possession DRPTS Revised 7/10 Initial: ________ Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com J. Transferred Assets Explanation: List the name and address of any person (other than your spouse and creditors listed on this affidavit) to whom you have given money or property exceeding $100.00 in value in the past 12 months. Present Fair Market Value Name and Address of Transferee Reason for Transfer Check box if subject of pending legal action. $ $ $ $ $ C. Unsecured Debts: If you do not know exact figures for any item, give your best estimate and write “EST.” List ALL UNSECURED DEBTS, INCLUDING CREDIT CARDS; (SECURED DEBTS SHOULD BE LISTED BESIDE THE ASSET SECURING THAT DEBT IN SECTIONS A & B ON PAGES 2 AND 3). If more space is needed, attach extra pages. See additional pages: YES Name of Creditor Purpose of Debt Last 4 digits of account # In name of H, W or Joint Used by H, W or Both Total Balance (principle and interest) Monthly Payment $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ D. Separate Property Claims as defined in Ohio Revised Code §3105.17(A)(6)(a) If more space is needed, attach extra pages. See additional pages: Category Description Inheritances Property Owned Before Marriage Passive Income and Appreciation Property Acquired after a Legal Separation Decree YES Present Fair Market Value Present Debt (If any) $ $ $ $ $ $ $ $ $ $ $ Initial: ________ $ $ Prenuptial Agreement Personal Injury Compensation Gifts Made Solely to One Spouse DRPTS Revised 7/10 Details supporting your claim of separate ownership $ Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com II. 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 $ $ $ C. Other Minor Children of Mine, NOT Living in My Household. Child’s Name Residing with Date of Birth Age Court Ordered Support Paid $ $ $ III. 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) $ $ $ $ % $ % IV. 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.) Husband/Father Wife/Mother Gross Annual Employment Income Wages $ Salary Salary Wages $ Name(s) of Employer(s) Payroll Address(es) City, State, Zip 52 26 24 12 52 26 24 12 Check the number of 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. DRPTS Revised 7/10 $ $ $ $ $ $ Initial: ________ Page 5 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Total Annual Value of Benefits: $ $ 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 C. Month Day Year 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: 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 D. 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 $ Wife/Mother Average Monthly Deductions Total Gross Fed/State/Local Annual 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 Total Average Gross Monthly Income Divide Gross Annual By 12 $ Taxes Social Security Medicare Health Insurance $ Average Monthly Deductions Minus Union Dues $ Pensions $ $ Pensions $ IRAs/401(k)s $ Available Monthly Income Equals IRAs/401(k)s $ Support Orders $ $ Support Orders $ Other: $ Other: Total Average Deductions $ $ Total Average Deductions $ $ $ $ DRPTS Revised 7/10 Initial: ________ $ $ Total Average Gross Monthly Income Divide Gross Annual By 12 Average Monthly Deductions Minus Available Monthly Income Equals $ $ $ Page 6 of 6 American LegalNet, Inc. www.FormsWorkFlow.com V. Affiant’s Monthly Living Expenses: On pages 7 and 8 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. Check box to right of each ESTIMATED expense 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) $ Work/Educational Related Childcare $ $ Clothing $ $ School Supplies $ $ Children’s Allowances $ Extracurricular Activities, Lessons $ School Lunches Other: $ $ Gas (if billed separately) $ 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 Cleaning Service Maintenance and home repairs Expenses LAWN SERVICE AND SNOW REMOVAL OTHER (specify): Life $ $ $ $ Renters/Personal Property Other (specify): $ $ Disability $ $ Health $ FOOD, ETC.: Groceries (include food, paper and cleaning products, toiletries, etc.) $ Auto Cable Television CLEANING, MAINTENANCE, REPAIR TOTAL HOUSING (A) B. OTHER MONTHLY LIVING EXPENSES Check box to right of each ESTIMATED expense 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 $ $ $ $ $ $ $ $ $ Prescriptions Other (specify): $ $ $ $ $ $ $ Total Health Care Expenses for Each Column. $ $ Children Optometrists/Opticians $ DRPTS Revised 7/10 You Dentists $ TOTAL OTHER LIVING EXPENSES (B) Check box to right of each ESTIMATED expense Physicians $ CELL PHONE OTHER (Specify): $ Initial: ________ TOTAL HEALTH CARE EXPENSES (F) (Add Both Columns) $ Page 7 of 7 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 in my household. $ 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 $ VI. 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 DRPTS Revised 7/10 Initial: ________ Page 8 of 8 American LegalNet, Inc. www.FormsWorkFlow.com