Court Form 2 Eff. 7/1/08 IN THE COMMON PLEAS COURT OF HURON COUNTY, OHIO DIVISION OF DOMESTIC RELATIONS Case No. : Plaintiff/Petitioner (1) : DOB CSEA No. : Address JUDGE JAMES W. CONWAY : : V. MAGISTRATE BRADLEY E. SALES : Defendant/Petitioner (2)/Respondent : DOB : Address : Affidavit of Income, Expenses and Property of (Name) : Date of Marriage Date of Separation Notes: This affidavit must be filed and served in accordance with Local Rules of Court. Pages 1 through 8 and page 13 must be completed and 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. 3119.021. You are under a continuing legal duty to file an updated version of this form if you learn of any additional information. If more space is needed, attach additional page(s). I. A. Income [As defined in O.R.C. 3119.01]: Gross Yearly Income from Employment (If not known, please estimate. Put “EST” after each estimated figure.) Husband/Father Wife/Mother Gross Yearly Employment Income Employer Payroll Address City, State, Zip Check the Number of Paychecks per Year G12 G24 Year-to-date Gross Income G26 G52 Through date of G12 G24 G26 G52 Through date of Prior Year’s Tax Refund Initialed Affidavit of Income, Expenses and Property Page 1 of 13 American LegalNet, Inc. www.FormsWorkflow.com B. Annual Overtime, Commissions, Bonuses (If not known, please estimate. Put “EST” after each estimated figure.) Husband/Father Year 3 is Most Recent Year 20__ Year 1 Base Income Wife/Mother Overtime, Commissions, Bonuses Year 3 is Most Recent Year 20__ Year 1 20__ Year 2 20__ Year 3 Year-to-Date This Year Through ____ Overtime, Commissions, Bonuses 20__ Year 2 20__ Year 3 Base Income Year-to-Date This Year Through ____ C. 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. 3119.021 Business Receipts Husband/Father Wife/Mother Ordinary & Necessary Business Expenses Net Business Income D. Other Income All other income, actual or expected, including pension, social security, workers compensation, commissions, royalties, disability benefits, trust income, annuities, recurring 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.) Husband/Father Per Year Wife/Mother Describe Initialed Per Year Describe Affidavit of Income, Expenses and Property Page 2 of 13 American LegalNet, Inc. www.FormsWorkflow.com E. Total Annual Income Husband/Father Wife/Mother Total gross annual income Total gross annual income Total average gross ÷ 12 = Total average gross ÷ 12 = Average monthly deductions Less Average monthly deductions Less Total net monthly income = Total net monthly income = F. Benefits of Employment (Use of company car, country club memberships, stock options, etc.) Husband/Father Benefits Wife/Mother Values Benefits II. Information Required for Support Calculation: A. Values Minor or Dependent Children of this Marriage (Include adopted children and any child of the parties who is over 19 and handicapped.) Child’s Name B. Residing With Other Minor Children Living in My Household Child’s Name C. Date of Birth Date of Birth Relationship Other Minor Children of Mine, Not Living in My Household Child’s Name Date of Birth Initialed Relationship Affidavit of Income, Expenses and Property Page 3 of 13 American LegalNet, Inc. www.FormsWorkflow.com III. Child Support Guidelines Adjustment: Husband/Father (All Figures Per Year) Wife/Mother (All Figures Per Year) or: or: 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 Children Living With You From a Previous Marriage or Relationship 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 Number of Your Other Dependent Children Living with You from Your Present Marriage or Relationship [Excluding unadopted step-children] 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 ANTICIPATEDexpenses 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 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: Initialed Anticipated Future Monthly Expenses in My Household The reason I expect my household living expenses to change soon is: Affidavit of Income, Expenses and Property Page 4 of 13 American LegalNet, Inc. www.FormsWorkflow.com A. Housing Actual Anticipated Rent or First Mortgage Real Estate Taxes (if not included above) Real Estate Insurance (if not included above) Second Mortgage, if any (or home equity loan) UTILITIES: • Electric (level billing or average/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 Other:____________________________________ Housing Total (A) B. Other Necessary Living Expenses Actual (A) Anticipated FOOD, ETC.: • Grocery (include food, paper & cleaning products, toiletries, etc.) • Restaurant TRANSPORTATION, ETC.: • Car Loan or Lease • Gasoline • Car Maintenance & Repair • Parking, Public Transit Initialed Affidavit of Income, Expenses and Property Page 5 of 13 American LegalNet, Inc. www.FormsWorkflow.com B. Other Necessary Living Expenses (Cont.) Actual Anticipated CLOTHING, ETC.: • Clothes • Dry Cleaning, Laundry • Personal Grooming Other: _________________________________ Other: _________________________________ (B) (B) Other Necessities Total C. Child-Related Expenses Actual Anticipated Child Care, Work or Educational Related Clothing School Lunches Children’s Allowances Extra-Curricular Activities Other: ________________________________ (C) (C) Child-Related Expenses Total Actual D. Educational Expenses for: You Anticipated Child(ren) You Child(ren) Tuition Books Fees Tutor Activities College Loan Repayment Other: ________________________________ (D) (D) Education Total Initialed Affidavit of Income, Expenses and Property Page 6 of 13 American LegalNet, Inc. www.FormsWorkflow.com Actual E. Medical Expenses (Out-of-pocket) for: You Anticipated Child(ren) You Child(ren) Doctor Dentist Optical Orthodontist Prescriptions Other: ________________________________ (E) (E) Medical Total F. Insurance Actual Anticipated Life Auto Health Disability COBRA Insurance Coverage Personal Property Other: ________________________________ (F) (F) Insurance Total G. Enrichment (Your expenses. Put child(ren)’s expenses under C or D, above) Actual Anticipated Entertainment Lessons Books, Newspapers, Magazines Initialed Affidavit of Income, Expenses and Property Page 7 of 13 American LegalNet, Inc. www.FormsWorkflow.com G. Enrichment (Cont.) Actual Anticipated Sports Clubs Hobbies Donations Gifts Vacation Other: ________________________________ (G) (G) Enrichment Total H. Miscellaneous Expenses (Include expenses and debts not previously listed.) Actual Anticipated 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. (H) (H) Miscellaneous Expenses Total Actual Anticipated Grand Total of Monthly Expenses (Sum of A - H in each column) Initialed Affidavit of Income, Expenses and Property Page 8 of 13 American LegalNet, Inc. www.FormsWorkflow.com AFFIDAVIT OF PROPERTY List ALL YOUR PROPERTY AND DEBTS, those of your spouse, and joint property and debts. Do not leave any category blank. For each item, if none, put “NONE.” If you don’t know exact figures for any item, give your best estimate, and put “EST”. If more space is needed, attach extra pages. I. Real Estate Interests: Address Titled to Husband, Wife or Both Present Fair Market Value Mortgages: Balance Due Monthly Mortgage Payments A. B. II. Other Assets Category A. Vehicles, Other Licensed Property Description (Also list who has possession) Present Fair Titled to Husband, Market Value (Also list balance Wife, or Both due on any liens) (Include automobiles, trucks, motorcycles, boats, motors, motor homes, etc.) 1. 2. 3. B. Financial Accounts (Include checking, savings, CD’s, POD accounts, money market accounts, etc.) 1. 2. 3. C. Pensions & Retirement Plans 1. (Include profit-sharing, IRA’s 401K plans, etc.) Describe each type of plan. 2. 3. D. Publicly Held Stocks, Bonds, Securities, & Mutual Funds 1. 2. 3. Initialed Affidavit of Income, Expenses and Property Page 9 of 13 American LegalNet, Inc. www.FormsWorkflow.com Category Description (Also list who has possession) Titled to Husband, Wife, or Both Present Fair Market Value (Also list balance due on any liens) E. Closely Held Stocks and (Describe type of business and type of Other Business Interests ownership.) 1. 2. F. Life Insurance (Include insurance provided by employer, term, whole life, any cash value or loans.) 1. 2. G. Furniture & Appliances (Estimate value of those in your possession and value of those in your spouse’s possession) 1. 2. H. Safe Deposit Box (Give location and describe contents) I. All Other Assets (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.) 1. 2. J. Transfer of Assets Explanation: List the name and address of any person [other than creditors listed on your Affidavit] who has received money or property from you exceeding $100 in value in the past 12 months and the reason for each transfer. 1. 2. K. Lost Assets Explanation: List any item you claim is lost or missing as of this date, and its value. 1. 2. Initialed Affidavit of Income, Expenses and Property Page 10 of 13 American LegalNet, Inc. www.FormsWorkflow.com III. Debts: List ALL YOUR DEBTS, debts of your spouse, and joint debts. Do not leave any category blank. For each item, if none, put “NONE”. If you don’t know exact figures for any item, give your best estimate, and put “EST.” If more space is needed, attach extra pages. Type Name of Creditor/ Purpose of Debt Total Debt Due Monthly Payment A. Secured Debts (Mortgages, car, etc.) 1. 2. 3. 4. B. Unsecured Debts (Including credit cards) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. IV. Bankruptcy: Filed by: Wife, Husband, Both Date of Filing; Case Number Date of Discharge or Relief from Stay Type of Case (Ch. 7, 11, 12, 13) Current Monthly Payments 1. 2. Initialed Affidavit of Income, Expenses and Property Page 11 of 13 American LegalNet, Inc. www.FormsWorkflow.com V. Separate Property Claims: [As defined in O.R.C. 3105.17(A)(6)(a)] If you are making any claims in any of the categories below, explain the nature and amount of your claim. Category Description Particulars leading to your claim of separate ownership Present Fair Market Value Present Debt A. Inheritances B. Property Owned Before Marriage C. Passive Income and Appreciation from Separate Property D. Property Acquired After a Decree of Legal Separation Initialed Affidavit of Income, Expenses and Property Page 12 of 13 American LegalNet, Inc. www.FormsWorkflow.com Category Description Particulars leading to your claim of separate ownership Present Fair Market Value Present Debt E. Prenuptial Agreement F. Personal Injury Compensation (Except Loss of Marital Earnings) G. Gifts Made Solely to One Spouse OATH OF AFFIANT I, _______________________________________ (print) hereby swear or affirm that the information set forth in this Affidavit of Income, Expenses and Property 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. 2921.22). ______________________________________________ AFFIANT Sworn to and subscribed before me this _________ day of ___________________________, _________ _________________________________________________ Notary Public Initialed Affidavit of Income, Expenses and Property Page 13 of 13 American LegalNet, Inc. www.FormsWorkflow.com