IN THE COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS LAKE COUNTY, OHIO ___________________________________Plaintiff CASE NO. _____________________________ vs ___________________________________Defendant ANSWER AFFIDAVIT of Respondent Now comes the Respondent and submits the following response to the Motion for Temporary Residential Parenting,Child Support and/or Spousal support of the Movant. __________________________________________ Respondent/Attorney for Plaintiff/Defendant (Print)___________________________________________ __________________________________________Respondent/Atty for __________________(signature) __________________________________________ Phone No:__________________________________ Atty. Registration No:_________________________State of Ohio ) The Respondent, being first duly sworn, says that the following answers are true to the best of County of Lake)ss: affiants knowledge and belief. I. INFORMATION MOVANT RESPONDENT Actual Address Birth Date Employer Employer Address Job Title Rate of Pay Date of Marriage Date of Separation II CHILDREN OF THE MARRIAGE NAME AGE DOB RESIDING WITHIII OTHER CHILDREN RESIDING WITH: MOVANT RESPONDENT American LegalNet, Inc. www.USCourtForms.com>>>> 2IV. FINANCIAL DEMANDS Child Support ________________________________________________________________________ __________ Spousal Support ________________________________________________________ ________________________ Other _________________________________________________________________________________________ V. FUNDS AVAILABLE (Monthly) MOVANT RESPONDENT DEDUCTIONS/ADJUSTMENTS 1. Salary/wages _________________________ MOVANT RESPONDENT 2. Overtime/bonus last calendar year_________________________ 27. Federal Tax ________________________ 3. Overtime/bonus 2 years ago _________________________ 28. State Tax ________________________ 4. Overtime/bonus 3 years ago _________________________ 29. City Tax ________________________ 5. Commissions _________________________ 30. FICA ________________________ 6. Royalties _________________________ 31. Estimated Tax ________________________ 7. Tips _________________________ 32. Hospitalization ________________________ 8. Rents _________________________ 33. Pension/Retirement _______________________ 9. Dividends _________________________ 34. Credit Union Loans________________________10. Severance pay _________________________ 35. Charity ________________________11. Pensions _________________________ 36. Credit Union Savings______________________12. Interest _________________________ Other (specify)_______________________________13. Trust Income _________________________ ___________________________________________14. Annuities _________________________ 37. ________________________________________15. Social Security Benefits (not 38. Union Dues _______________________ means tested): Retirement _________________________ TOTAL DEDUCTIONS Disability _________________________ 39. (Lines 27 thru 38) ________________________ Survivor benefits _________________________ 40. TOTAL FUNDS 16. Workers Compensation _________________________ AVAILABLE 17. Unemployment insurance benefits________________________ (26 minus 39) ________________________18. Disability insurance benefits _________________________ 19. Veteran benefits (not means tested) Actually received & in pos- session _________________________ 20. Spousal support actually receive _________________________ 21. Other sources (state below) ________________________ ________________________ ________________________ 22. Military or National guard pay for: Base pay _________________________ Quarters allowance _________________________ Subsistence allowance _________________________ Cost of living adjustment _________________________ Specialty pay _________________________ Housing allowance _________________________ Training _________________________ 23. Net business income _________________________ 24. Personal earnings _________________________ 25. Self-generated income _________________________ 26. TOTAL INCOME (1 - 25) _________________________ VI. ADDITIONAL INFORMATION: If you need to set forth additional information on any relevant item, please do so here or attach the information on a separate sheet American LegalNet, Inc. www.USCourtForms.com>>>> 3CURRENT MONTHLY FINANCIAL Part I Part IIREQUIREMENTS OF AFFIANT AND Husband/Father/Other Wife/Mother/Other_________________________________ a)Address ______________ Is family health insurance ______________ available either through the b) Names, ages and relationship ______________ employer or another group of others at this address ______________ or organization? ___ yes ___no ___yes ___no ______________ 1. Mortgage ______________ If not, is private insurance 2. Rent ______________ available? ___ yes ___no ___yes ___no 3. Phone ______________ 4. Electric ______________ Is coverage Presently in effect?___ yes ___no ___yes ___no 5. Gas ______________ 6. Water ______________ Who is presently covered: 7. Sewer ______________ Name: ______________ _____________ 8. Garbage ______________ Relationship: ______________ _____________ 9. Food ______________ Name: ______________ _____________10. Health Insurance ______________ Relationship: ______________ _____________11. Medical/Dental ______________ Name: ______________ _____________12. Clothing ______________ Relationship: ______________ _____________13. Auto Payments ______________ Name: ______________ _____________14. Auto Gasoline ______________ Relationship: ______________ _____________15. Auto Insurance ______________ Insurer: Plan Name ______________ _____________16. Auto Maintenance ______________ Phone Number ______________ _____________17. Real Estate Tax ______________ Address ______________ _____________18. Real Estate Insurance ______________ ______________ _____________19. Home Maintenance ______________ Policy/Group # ______________ _____________20. School ______________ Other Policy # ______________ _____________21. Child Care ______________ (if another policy is available) 22. Haircuts ______________ Is there a cost for coverage? ___ yes ___no ___yes ___no23. Life Insurance ______________ *What is the annual cost for 24. Finance Companies ______________ Family coverage? $_____________ $_____________25. Charge Cards ______________ *What is the annual cost for 26. Union Dues ______________ Individual coverage? $_____________ $_________