IN THE COMMON PLEAS COURT OF LAKE COUNTY, OHIO DIVISION OF DOMESTIC RELATIONS _____________________________________ CASE NO. ________________________________ Plaintiff/DOB CSEA NO. ________________________________ _____________________________________ Attorney Name and Registration No. JUDGE COLLEEN A. FALKOWSKI _____________________________________ Attorney Address MAGISTRATE _____________________________ _____________________________________ Attorney Phone -vs- _____________________________________ Defendant/DOB _____________________________________ Attorney Name and Registration No. _____________________________________ Attorney Address _____________________________________ Attorney Phone AFFIDAVIT OF INCOME, EXPENSES AND PROPERTY OF: _________________________ __ In accordance with Local Rules 3.02 and 9.01, this Affidavit must be filed and served in every divorceand legal separation and shall be updated as needed. If more space is needed, attach additional page( s). Date of Marriage __________________ Date of Separation ________________ 1. Information Required for Support Calculations: A. Minor or Dependent Children of Either/Both Parties: A. Include adopted children and any child of this marriage who is over 18 years of age and handicapped. Childs Name Date of Birth Gender Age Residing With: B. Other Minor Children Living in my Household: Childs Name Date of Birth Gender Age Residing With: American LegalNet, Inc. www.USCourtForms.com Initialed ________________ Financial Disclosure Affidavit Page 1>>>> 2C. Other Minor Children of Mine, Not Living in My Household Childs Name Date of Birth Male / Female Age Residing with II. Child Support Guideline Adjustment: Husband/Father Wife/Mother (All Figures Per Year) (All Figures Per Year) 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) III. Income [As defined in O.R.C. 3119.01(C)(7)]: A. Gross Yearly Income from Employment (If not known, please estimate. Put EST after each estimated f igure.) Husband / Father Wife / Mother Gross Yearly Gross Yearly Employment Employment Income Income Employer Employer Payroll Address Payroll Address City, State, Zip City, State, Zip Check the number Check the number of Paychecks per o 12 o 24 o 26 o 52 of Paychecks per o 12 o 24 o 26 o 52 year year Year-to-date Through date of Year-to-date Through date of Gross Income Gross Income Prior Years Prior Years Tax Refund Tax Refund Initialed Financial Disclosure Affidavit Page 2 American LegalNet, Inc. www.USCourtForms.com>>>> 3B. Annual Overtime, Commissions, Bonuses (If not known, please estimate. Put EST after each estimated f igure.) Husband / Father Wife / Mother Year 3 is Most Overtime, commission, Year 3 is Most Overtime, Recent Year Base Income Bonuses Recent Year Base Income commission, Bonuses _____ Year 1 _____ Year 1 _____ Year 2 _____ Year 2 _____ Year 3 _____ Year 3 Y-T-D This Year Y-T-D This Year Through: Through: C. Gross Self -Employment Income (If not known, please estimate. Put EST after each estimated figure.) U se Gross Annual Figures for Most Recent Full Year. See O.R.C. 3119.01(C)(7) Husband / Father Wife / Mother Business Receipts Business Receipts Ordinary & Ordinary & Necessary Necessary Business Business Expenses Expenses Net Business Net Business Income Income D. Other Income All other income, actual or expected, including pension, social security , workers compensation, commissions, royalties, disability benefits, trust income, annuities, reoccurring capital gains, unemployment benefits, re nts, expense-sharing, dividends, interest, AFDC, SSI, food stamps, spousal support received from a prior spouse, etc. (If not know n, please estimate. Put EST after each estimated figure.) Husband / Father Wife / Mother Describe Per Year Describe Per Year E. Total Annual Income Husband / Father Wife / Mother Total gross annual Total gross annual income income Total average gross Total average gross 12 = 12 = monthly income monthly income Average monthly Less Average monthly Less deductions deductions Total net monthly income Total net monthly = income = F. Benefits of Employment (Use of company car, country club memberships, stock options, etc.) Husband / Father Wife / Mother Benefits Values Benefits Values Initialed Financial Disclosure Affidavit Page 3 American LegalNet, Inc. www.USCourtForms.com>>>> 4IV. Affiants Monthly Living Expenses List your ACTUAL expenses for your present household. Give estimated expenses if you dont have exact figures. If you expect changes soon, list your ANTICIPATED expenses in your household after the divorce case. Explain why you exp ect your expenses to change. Also, if you are living with your parents or someone is helping you with your living expenses, please explain. There are now Adults and Children living in I am assisted with my The reason I expect my my present household. living expenses by: household living expenses to change soon is: A. Housing Actual or Anticipated B. Other Necessary Actual or Anticipated Living Expenses (Circle One) (Circle One) Rent or First Mortgage FOOD, ETC.: (circle which one) Grocery (include food, paper & cleaning products, toiletries, etc.) Real Estate Taxes (if not Restaurant included above) Real Estate Insurance (if TRANSPORTATION, ETC. not included above) Car Loan or Lease Second Mortgage, if any Gasoline UTILITIES: Car Maintenance & Electric (level billing or Repair avg/month) Gas (if billed separately) Parking, Public Transit Fuel Oil/Propane CLOTHING, ETC.: Clothes Water & Sewer Dry Cleaning, Laundry Telephone (basic PERSONAL GROOMING monthly charge) (average long distance) Water Softener Other: Trash Collection Cable Television Home Cleaning, Maintenance, Repair Lawn Service, Snow Removal Other: Housing Total (A) Other Necessaries Total (B) C. Child-Related Expenses Actual or Anticipated D. Educational Expenses Actual or Anticip