1 NOTE: EACH PARTY TO COMPLETE FORM FOR SELF AND OPPOSING PARTY. USE A SEPARATE PAGE FOR EACH EMPLOYMENT. Form 4.01D Rev. 8/2018 IN THE COURT OF COMMON PLEAS DOMESTIC RELATIONS DIVISION MEDINA COUNTY, OHIO ) CASE NO. Plaintiff ) ) JUDGE MARY KOVACK ) vs. ) AFFIDAVIT IN SUPPORT OF ) MOTION FOR TEMPORARY ) SPOUSAL SUPPORT, CHILD ) SUPPORT AND/OR CUSTODY Defendant ) PURSUANT TO CIV.R. 75(N) NOTE : This document should not be filed with the Clerk of Courts, but should be submitted to the . Now comes Plaintiff / Defendant [select one] and states as follows: I. GENERAL INFORMATION 1. I am years old. 2. My current residential address is: . My rent / mortgag e is : per month. My spouse is / is no t living at this address. 3. Names and ages of minor children of this marriage: . 4. Children reside w ith whom and where : . 5. I am employed by: . . My gross pay is : $ per [pay period]. Sources and amounts of other income, if any : . 6. My Social Security Number is: . 7. My birthdate is: [month, day, year] . 8. My spouse is employed by: . His/her . per [pay period]. Sources and amounts of other income, if any: . American LegalNet, Inc. www.FormsWorkFlow.com 2 NOTE: EACH PARTY TO COMPLETE FORM FOR SELF AND OPPOSING PARTY. USE A SEPARATE PAGE FOR EACH EMPLOYMENT. Form 4.01D Rev. 8/2018 II. INCOME OF PLAINTIFF / DEFENDANT [select one] I am Full - time / Part - time [check one]. I am employed by: My gross pay is: $ per [ e.g. , bi - weekly, bi - monthly] . Other source(s) and amount(s) of income, if any, Deductions (per pay period) Amount of Deduction Frequency of Deductions ( e.g. , per pay , per month ) Federal Income Taxes $ State Income Taxes $ Local Income Taxes $ Medical Insurance $ Dental Insurance $ Life Insurance $ Social Security $ Medicare $ Pension, 401k or other retirement $ Union Dues $ Other [savings, loans, 401k repay, etc.] $ N ET W AGES FROM E MPLOYMENT : $ Other Income Amount Food Stamps/Other Assistance $ Social Security/SSI/SSDI $ Ohio Works First $ Medicaid $ N ET O THER I NCOME : $ American LegalNet, Inc. www.FormsWorkFlow.com 3 NOTE: EACH PARTY TO COMPLETE FORM FOR SELF AND OPPOSING PARTY. USE A SEPARATE PAGE FOR EACH EMPLOYMENT. Form 4.01D Rev. 8/2018 III. EXPENSES OF PLAINTIFF / DEFENDANT [select one] Please provide average monthly expenses for yourself, and for your children, but if only if you are the residential parent. If you are not the residential parent and not living at the family home, please provide expenses for yourself only. Please state names and relationship of all members of the household whose expenses are included: I TEM M ONTHLY A MOUNT 1. FOOD and miscellaneous non - food items purchased with groceries $ 2. SHELTER Mortgage / Rent $ Real Estate Taxes [if not escrowed in mortgage payment] $ Home Insurance [if not escrowed in mortgage payment] $ Electricity $ Heat $ Water $ Telephone $ Repairs, maintenance, etc. $ Water Softener $ Trash Collection $ Cable Television $ Lawn service/snow removal $ 3. AUTOMOBILE AND TRANSPORTATION Car Loan or Lease Payment $ Gasoline $ Repairs $ Automobile Insurance $ Public Transportation $ 4. PERSONAL INSURANCE [not otherwise deducted from wages] Health $ Dental $ Life $ Accident and Disability $ Unreimbursed medical expenses $ 5. CLOTHING, ETC. Clothes $ Dry cleaning/laundry $ Haircuts/personal grooming $ American LegalNet, Inc. www.FormsWorkFlow.com 4 NOTE: EACH PARTY TO COMPLETE FORM FOR SELF AND OPPOSING PARTY. USE A SEPARATE PAGE FOR EACH EMPLOYMENT. Form 4.01D Rev. 8/2018 6 . CHILD - RELATED EXPENSES Child care, work or education related $ School lunches $ $ Lessons $ Extra - Curricular Activities $ Other [speci fy] : $ 7. MISCELLANEOUS Books, newspapers, magazines $ Gifts $ Vacation $ Extraordinary pet expenses $ Donations $ Entertainment $ Other [specify]: $ 8. PRE - EXISTING COURT - ORDERED SUPPORT FROM PRIOR CASE(S): Child Support $ Spousal Support $ N ET T OTAL E XPENSES : $ Installment obligations, other than mortgage, i.e., finance companies, department stores, credit cards, medical, hospital debts: If additional space is needed, use the back of this form. Indicate HWJ C REDITOR A MOUNT OWED M ONTHLY P AYMENT D EBTOR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ N ET T OTAL : $ $ American LegalNet, Inc. www.FormsWorkFlow.com 5 NOTE: EACH PARTY TO COMPLETE FORM FOR SELF AND OPPOSING PARTY. USE A SEPARATE PAGE FOR EACH EMPLOYMENT. Form 4.01D Rev. 8/2018 This information is, to the best of my knowledge, true and complete based upon information given to me by my client and through discovery, if any, and may be admitted into evidence upon trial of this case. Counsel for Plaintiff Defendant 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. Signature Plaintiff Defe ndant Sworn before me and signed in my presence on , 20 . Notary Public My Commission Expires: American LegalNet, Inc. www.FormsWorkFlow.com