IN THE COMMON PLEAS COURT OF GREENE COUNTY, OHIO DIVISION OF DOMESTIC RELATIONS _____________________________ Case No. _______________ Plaintiff/Petitioner Obligor/Obligee Address: ___________________________________ ___________________________________________ DOB: ______________ CSEA No. __________________ -vs- / -and___________________________________ Defendant/Petitioner Obligor/Obligee Address: ___________________________________ ___________________________________________ DOB: ______________ JUDGE STEVEN L. HURLEY Affidavit of Income and Expenses and Financial Disclosure ___________________________________________________________________________________________________________ State of Ohio, SS: Now comes_______________________________, Affiant/Petitioner herein, being first duly cautioned and sworn and states as follows: I.TEMPORARY ORDERS (please check all that apply) ___ I do not request a temporary order ___ I request a temporary order for __ custody, __ child support, and/or __ spousal support. ___ A Domestic Violence Order under Case No. _____________ was filed on _______________. ___ A Bankruptcy action under Case No. ________________ was filed on __________________. ___ The parties are presently residing together. II. CHILDREN OF THIS MARRIAGE 1. _________________________, SSN _________________, DOB ___________ residing with ________________. 2. _________________________, SSN _________________, DOB ___________ residing with ________________. 3. _________________________, SSN _________________, DOB ___________ residing with ________________. 4. _________________________, SSN _________________, DOB ___________ residing with ________________. III. DOMESTIC VIOLENCE SCREENING (ORC SEC. 3109.052) 1. Has either Parent been convicted of domestic violence or any other offence involving physical harm or the threat of physical harm to a victim who is named in this affidavit or has been found to have engaged in child abuse? YES ___ (Plaintiff) (Defendant) NO ___ 2. Is either party the subject of a Protection Order in Ohio or any other State? YES ____ (Plaintiff) (Defendant) NO ____ American LegalNet, Inc. www.USCourtForms.com IV. WAGES, EARNING AND INCOME (Put your yearly and best estimate of the other Petitioner) A. Gross Yearly Income From Employment (Including self-employment) Plaintiff/First Petitioner Defendant/Second Petitioner _______yes ________ no ………………………..Employed…………………………..…________ yes ________no $___________________(Actual/Estimated).Based yearly Wages.(Actual/Estimated) $ _____________________ _________________________________..............Employer…….........____________________________________ __________________________________.........Payroll Address…….. _____________________________________ __________________________________........ City, State, Zip…. …______________________________________ B. Other Yearly Income - Defined as Interest Dividend Income, Unemployment Compensation, Workers Compensation, Social Security or other disability benefits, Social Security/Pension Income, etc. Plaintiff/First Petitioner Source of Income Defendant/Second Petitioner Source of Income Yearly Amount Yearly Amount _____________________ $______________ ________________________ $____________ _____________________ $______________ ________________________ $____________ Please note – Wage earners must attach a copy of their most recent wage-earning statement/pay stub. Self-employed individuals must attach a copy of Schedule C of IRS Form 1040 from most recent tax reporting period. V. ASSETS AND LIABILITIES (Use additional sheet if necessary) 1. Retirement Benefits: Name and Address of Retirement/Pension Plan Account # _____________________________________________ _________________ Present Value _______________ ______________________________________________ _________________ _______________ ______________________________________________ _________________ _______________ 2. Real Estate: Address of Property Name on Deed Present Value ______________________________ _______________________ ______________ ______________________________ _______________________ ______________ ______________________________ _______________________ ______________ 3. Financial Accounts: List all bank, savings and loan, credit union, regulated Investment Company, mutual fund, bonds, securities, stocks, certificates of deposit, individual retirement accounts and all other financial accounts wherein you possess any interest. Name of Financial Institution Address Account # Names Value _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ American LegalNet, Inc. www.USCourtForms.com 4. Liabilities/Debt: (Monthly Installment Payments, i.e. Car Payments, Loans, etc…) Name of Creditor Purpose of Debt Balance Due Payment __________________ ______________ __________ __________ __________________ ______________ __________ __________ __________________ ______________ __________ __________ __________________ _______________ __________ __________ __________________ _______________ __________ __________ VI. AFFIANT/PETITIONER’S MONTHLY LIVING EXPENSES: List your actual expense for your present household only. Do not duplicate expenses previously listed in this affidavit. If the children are living with you, calculate expenses below for you and the children combined. A. Monthly Expenses 1. Housing Rent or Mortgage (including taxes and insurance)…………………. ……………………....$______________ a. Gas & Electric (level billing or average per month)…………………………………….. $______________ b. Water and Sewer…………………………………………………. …………………….. $______________ c. Telephone (excluding long distance)……………………………. ……………………….$______________ d. Trash Collection…………………………………………………………………………..$______________ e. Other_____________________________________..........................................................$______________ Housing Total ……………………………………………………………………………... $______________ 2. Other Monthly Expenses f. Child Care ……………………………………………………………………………….. $______________ g. Grocery (include food, laundry & cleaning products, etc.) ……. ………………………. $______________ h. Gasoline & Oil …………………………………………………………………………...$______________ i. Car repairs ……………………………………………………………………………….. $______________ j. Insurance (auto, life, home) ……………………………………………………………… $ _____________ k. Medical (not covered by insurance) ………………………………………………………$______________ l. Clothing ………………………………………………………….. ………………………$______________ m. Court ordered child support for children not of this marriage ……………………………$______________ n.. Other ____________________________________...........................................................$______________ Other Monthly Expenses Total ……………………………………. ………………………$______________ Total of 1 and 2 ……………………………………………………… ………………………$______________ American LegalNet, Inc. www.USCourtForms.com VII. HEALTH INSURANCE: Plaintiff/Petitioner Defendant/Respondent YES / NO………………..Available Through Employment……..……...YES / NO YES / NO…………………......Other Group Plan ……..………………..YES / NO ___________________________________ ______ ______________________________ ___________________________________ ______________________________________ ___________________________...... ............Policy Number…….……___________________________________ _________________________......Employee Cost Per year for Individual Plan……_________________________ __________________________.......Employee cost Per Year for Family Plan ……__________________________ _________________________________________________________________________________________________ Affiant/Petitioner states that the information contained herein and attached hereto is complete and accurate to the best of his/her knowledge and/or belief under penalty of law. ________________________________ ______________________________________ Signature of Affiant/Petitioner Signature of Attorney for Affiant/Petitioner Sworn to and subscribed in my presence this __________day of ________________, 20___. _____________________________ NOTARY PUBLIC My commission expires: _________________ Revised 5-16-2005 American LegalNet, Inc. www.USCourtForms.com