IN THE COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS MAHONING COUNTY, OHIO CASE NO. ____________________ ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) _________________________________________________________________ _______________________________________________ _______________________________________________ EMPLOYER:___________________________________ PLAINTIFF/PETITIONER VS./AND ______________________________________________ ______________________________________________ ______________________________________________ EMPLOYER:__________________________________ DEFENDANT/PETITIONER Revised 11/10/08 JUDGE BETH A. SMITH AFFIDAVIT OF INCOME, EXPENSES AND FINANCIAL DISCLOSURE OF _________________________________ STATE OF OHIO, SS: Now comes _____________________________, being first duly sworn, states that he/she has been advised that this Affidavit may be used for any or all of the following purposes: (1) to make complete disclosure of affiant's income, liabilities and expenses; (2) to assist in determining orders of child support or spousal support when applicable or any changes thereto; and (3) to provide for the issuance of the appropriate deduction order for support. Date of Marriage ______________________________ Date of Separation ___________________________ Date of Divorce/Dissolution Decree (If Post-Decree Case) _____________________ Minor and/or Dependent Children of this Marriage: 1._________________________________ DOB __________ 4._____________________________ DOB__________ 2._________________________________ DOB __________ 5._____________________________ DOB__________ 3._________________________________ DOB __________ 6._____________________________ DOB__________ MOTHER/WIFE EMPLOYER/PAYOR FATHER/HUSBAND EMPLOYER/PAYOR Name of Employer ______________________________________ Payroll Address City, State, Zip 12 24 26 52 (Circle One) ______________________________________ ______________________________________ Paychecks Per Year (Circle One) 12 24 26 52 ATTACH A COPY OF 3 RECENT PAYSTUBS AND W-2 OR FEDERAL INCOME TAX RETURN FOR LAST YEAR SECTION I. GROSS INCOME 1 American LegalNet, Inc. www.FormsWorkflow.com FATHER/HUSBAND MOTHER/WIFE $ Year 3 - 20___ $ Yearly Income from Employment Three years ago $________________ Year 3 - 20___ $_________ Year 2 - 20___ $ Two years ago Year 2 - 20___ $_________ Year 1 - 20___ $ Last Calendar Year Year 1 - 20___ $_________ $____________________________ Yearly Average Overtime, Commission & Bonus Income $__________________________ (Average of Past Three Years) $____________________________ Unemployment benefits $__________________________ $____________________________ Worker's Compensation $__________________________ $____________________________ Social Security or Other Disability Benefits (Identify) $__________________________ $____________________________ Retirement Benefits $__________________________ $____________________________ Interest/Dividend Income $__________________________ $____________________________ Other Income Received (Identify) -- (inc. spousal support) $__________________________ $____________________________ TOTAL YEARLY INCOME $__________________________ ADJUSTMENTS $_____________________ per year Court Ordered Support Paid for other child(ren) $____________________ per year $_____________________ per year Court Ordered Spousal Support Paid to any Spouse $____________________ per year ____________________________ Number of Other Dependent Children living with the Party (Excluding Unadopted Step Children) ___________________________ $______________________ per year $______________________ per year Child Support Received for Other Dependent Children Indicated Immediately Above $____________________ per year Health Insurance Premium Paid Family plan cost less Individual plan cost $____________________ per year $______________________ per year Local Income Taxes Paid $____________________ per year $______________________per year Self-Employment Tax (5.6% of AGI) $____________________ per year $______________________per year Other (Union dues, etc.) $____________________per year $______________________per year Work Related Child Care Expense $____________________ per year SECTION II. AFFIANT'S MONTHLY EXPENSES 2 American LegalNet, Inc. www.FormsWorkflow.com (Omit this section if filing with post-divorce Motion) A. HOUSING: 1. Rent or Mortgage (circle one) 2. Taxes (only if not incl. in mortgage) 3. Insurance (only if not incl. in mtg.) 4. Second Mortgage $________________ $________________ $________________ $________________ B. 1. 2. 3. 4. 5. 6. $________________ $________________ $________________ $________________ $________________ $________________ UTILITIES: Gas Electric Water & Sewer Telephone Trash Collection Cable Television F. 1. 2. 3. 4. 5. TRANSPORTATION: Car Payment (H) Car Payment (W) Car Insurance Gas and Oil Maintenance/Repair G. INSURANCE: 1. Life 2. Health 3. Disability $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ H. CHILDCARE: 1. Work Related $_____________ $_____________ 2. Other C. FOOD: 1. Groceries 2. School Lunches $________________ $________________ $_____________ D. MEDICAL: 1. Doctor 2. Dentist/Orthodontist 3. Prescriptions $________________ $________________ $________________ I. OTHER: 1.____________________ $_____________ 2.____________________ $_____________ $_____________ $_____________ $_____________ 7.______________________ 8.______________________ E. CLOTHING: 1. Regular 2. Dry Cleaning 3.____________________ 4.____________________ 5.____________________ 6.____________________ $______________ $______________ $__________________ $__________________ TOTAL MONTHLY EXPENSES: $___________________ SECTION III. MONTHLY INSTALLMENT PAYMENTS (Omit this section if filing with post-divorce Motion) CREDITOR: DEBTOR (H, W, JT) 1.__________________ ____ 2.__________________ ____ 3.__________________ ____ 4.__________________ ____ 5.__________________ ____ 6.__________________ ____ 7.__________________ ____ 8.__________________ ____ REASON FOR LOAN ORIGINAL AMT ________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ $____________ $____________ $____________ $____________ $____________ $____________ $____________ $____________ MONTHLY PMT $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ BALANCE $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ TOTAL MONTHLY INSTALLMENT PAYMENTS: $__________________ 3 American LegalNet, Inc. www.FormsWorkflow.com SECTION IV. FINANCIAL DISCLOSURE (Omit this section if filing with post-divorce Motion) A. List all funds on deposit in any and all accounts in any bank, savings & loan, credit union, regulated investment company, mutual fund or other financial institution. Account includes any of the following: checking, certificate of deposit ("CD"), investment, savings, individual retirement ("IRA"), stock option, etc. Attach additional pages if needed. Name & Address of Financial Institution Name(s) on Account Account No. (Last 4 digits) Balance on Date of this Affidavit __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ B. Other income sources listed in Section I (i.e., retirement/pension benefits, disability income, interest or dividend income, rental, annuities, etc.). Attach additional pages if needed. Name & Address of Source ___________________________ ___________________________ ___________________________ Identifying Description (Account No., Claim No., etc.) Income or Benefits _________________________________ _________________________________ _________________________________ $___________ per ________ $___________ per ________ $___________ per ________ CERTIFICATION Affiant states that the information contained herein is complete and accurate to the best of his/her information, knowledge or belief under penalty of law. Further, Affiant certifies that (s)he has caused a copy hereof to be mailed or delivered to the other party at the time of filing same with the Court. _________________________________________________ AFFIANT SWORN TO before me and subscribed in my presence, this ____ day of ______________, 20___. ___________________________________________________ NOTARY PUBLIC 4 American LegalNet, Inc. www.FormsWorkflow.com