COURT OF COMMON PLEAS COUNTY, OHIO Case No. Plaintiff/Petitioner Judge v./and Magistrate Defendant/Petitioner Instructions: Check local court rules to determine when this form must be filed. This affidavit is used to make complete disclosure of income, expenses and money owed. It is used to determine child and spousal support amounts. Do not leave any category blank. Write "none" where appropriate. If you do not know exact figures for any item, give your best estimate, and put "EST." If you need more space, add additional pages. AFFIDAVIT OF INCOME AND EXPENSES Affidavit of (Print Your Name) Date of marriage Date of separation Husband Employed Employer Payroll address Payroll city, state, zip Scheduled paychecks per year A. SECTION I - INCOME Wife Yes No Yes No 12 24 26 52 12 24 26 52 YEARLY INCOME, OVERTIME, COMMISSIONS AND BONUSES FOR PAST THREE YEARS Husband $ 3 years ago 2 years ago Last year 3 years ago 2 years ago Last year Wife 20 20 20 20 20 20 $ $ $ $ $ $ Base yearly income $ $ $ $ $ Yearly overtime, commissions and/or bonuses Supreme Court of Ohio Uniform Domestic Relations Form ­ Affidavit 1 Affidavit of Income and Expenses Approved under Ohio Civil Rule 84 Effective Date: July 1, 2010 Page 1 of 7 American LegalNet, Inc. www.FormsWorkFlow.com B. COMPUTATION OF CURRENT INCOME Husband Wife $ Base yearly income Average yearly overtime, commissions and/or bonuses over last 3 years (from part A) Unemployment compensation Disability benefits Workers' Compensation Social Security Other: Retirement benefits Social Security Other: Spousal support received Interest and dividend income (source) $ $ $ $ $ $ $ $ $ $ $ $ Other income (type and source) $ $ TOTAL YEARLY INCOME $ $ $ Supplemental Security Income (SSI) or public assistance Court-ordered child support that you receive for minor and/or dependent child(ren) not of the marriage or relationship $ $ $ $ Supreme Court of Ohio Uniform Domestic Relations Form ­ Affidavit 1 Affidavit of Income and Expenses Approved under Ohio Civil Rule 84 Effective Date: July 1, 2010 Page 2 of 7 American LegalNet, Inc. www.FormsWorkFlow.com SECTION II ­ CHILDREN AND HOUSEHOLD RESIDENTS Minor and/or dependent child(ren) who are adopted or born of this marriage or relationship: Name Date of birth Living with In addition to the above children there is/are in your household: adult(s) other minor and/or dependent child(ren). SECTION III ­ EXPENSES List monthly expenses below for your present household. A. MONTHLY HOUSING EXPENSES $ $ $ $ Rent or first mortgage (including taxes and insurance) Real estate taxes (if not included above) Real estate/homeowner's insurance (if not included above) Second mortgage/equity line of credit Utilities o o o o o o Electric Gas, fuel oil, propane Water and sewer Telephone Trash collection Cable/satellite television $ $ $ $ $ $ $ $ $ $ TOTAL MONTHLY : $ Cleaning, maintenance, repair Lawn service, snow removal Other: Supreme Court of Ohio Uniform Domestic Relations Form ­ Affidavit 1 Affidavit of Income and Expenses Approved under Ohio Civil Rule 84 Effective Date: July 1, 2010 Page 3 of 7 American LegalNet, Inc. www.FormsWorkFlow.com B. OTHER MONTHLY LIVING EXPENSES Food o o Groceries (including food, paper, cleaning products, toiletries, other) Restaurant $ $ Transportation o o o o Clothing o o Vehicle loans, leases Vehicle maintenance (oil, repair, license) Gasoline Parking, public transportation $ $ $ $ Clothes (other than children's) Dry cleaning, laundry $ $ Personal grooming o o Hair, nail care Other $ $ $ $ $ TOTAL MONTHLY $ Cell phone Internet (if not included elsewhere) Other C. MONTHLY CHILD-RELATED EXPENSES (for children of the marriage or relationship) $ $ $ $ $ $ $ $ $ $ TOTAL MONTHLY $ Work/education-related child care Other child care Unusual parenting time travel Special and unusual needs of child(ren) (not included elsewhere) Clothing School supplies Child(ren)'s allowances Extracurricular activities, lessons School lunches Other Supreme Court of Ohio Uniform Domestic Relations Form ­ Affidavit 1 Affidavit of Income and Expenses Approved under Ohio Civil Rule 84 Effective Date: July 1, 2010 Page 4 of 7 American LegalNet, Inc. www.FormsWorkFlow.com D. Life Auto INSURANCE PREMIUMS $ $ $ $ $ $ TOTAL MONTHLY $ Health Disability Renters/personal property (if not included in part A above) Other E. MONTHLY EDUCATION EXPENSES Tuition o o Self Child(ren) $ $ $ $ $ $ TOTAL MONTHLY: $ Books, fees, other College loan repayment Other F. MONTHLY HEALTH CARE EXPENSES (not covered by insurance) $ $ $ $ $ $ TOTAL MONTHLY: $ Physicians Dentists Optometrists/opticians Prescriptions Other G. MISCELLANEOUS MONTHLY EXPENSES $ $ $ $ $ Extraordinary obligations for other minor/handicapped child(ren) (not stepchildren) Child support for children who were not born of this marriage or relationship and were not adopted of this marriage Spousal support paid to former spouse(s) Subscriptions, books Entertainment Supreme Court of Ohio Uniform Domestic Relations Form ­ Affidavit 1 Affidavit of Income and Expenses Approved under Ohio Civil Rule 84 Effective Date: July 1, 2010 Page 5 of 7 American LegalNet, Inc. www.FormsWorkFlow.com Charitable contributions Memberships (associations, clubs) Travel, vacations Pets Gifts Bankruptcy payments Attorney fees Required deductions from wages (excluding taxes, Social Security and Medicare) (type) Additional taxes paid (not deducted from wages) (type) Other $ $ $ $ $ $ $ $ $ $ $ TOTAL MONTHLY: $ H. MONTHLY INSTALLMENT PAYMENTS (Do not repeat expenses already listed.) Examples: car, credit card, rent-to-own, cash advance payments To whom paid Purpose $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ TOTAL MONTHLY: GRAND TOTAL MONTHLY EXPENSES (Sum of A through H): Balance due $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Monthly payment Supreme Court of Ohio Uniform Domestic Relations Form ­ Affidavit 1 Affidavit of Income and Expenses Approved under Ohio Civil Rule 84 Effective Date: July 1, 2010 Page 6 of 7 American LegalNet, Inc. www.FormsWorkFlow.com OATH (Do not sign until notary is present.) I, (print name) , swear or affirm that I have read this document and, to the best of my knowledge and belief, the facts and information stated in this document are true, accurate and complete. I understand that if I do not tell the truth, I may be subject to penalties for perjury. Your Signature Sworn before me and signed in my presence this day of Notary Public My Commission Expires: , . Supreme Court of Ohio Uniform Domesti