DR-10 (1/11) IN THE COMMON Revised Montgomery County April 2016 PLEAS COURT OF MONTGOMERY COUNTY, OHIO DIVISION OF DOMESTIC RELATIONS CASE NO. PLAINTIFF/PETITIONER (1) Address: SETS NO. JUDGE: DOB: -vs- / -and- CROSS / WOOD AFFIDAVIT OF FINANCIAL DISCLOSURE (MONT. D. R. RULE 4.10) DEFENDANT/PETITIONER (2) Address: DOB: STATE OF OHIO, SS: Now comes _______________________________, affiant herein, and having been duly cautioned and 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 support when applicable. I. TEMPORARY ORDERS/OTHER ACTIVE CASES: I do not request a temporary order. I request a temporary order for ___________ custody, ___________ child support, and/or _____________ spousal support. A Domestic Violence Order under Case No. ________________________________________________ currently is in effect. A UIFSA or Juvenile Court Case under Case No. ____________________________________________ currently is in effect. A Bankruptcy action under Case No. _______________________ was filed ________________________________________. DATE OF SEPARATION (NEW CASES) ______________________________________ II. MINOR AND/OR DEPENDENT CHILDREN ONLY OF THIS MARRIAGE: ___________________________________________DOB:____________________Residing with_________________________________ ___________________________________________DOB:____________________Residing with_________________________________ ___________________________________________DOB:____________________Residing with_________________________________ ___________________________________________DOB:____________________Residing with_________________________________ EMPLOYMENT OR SCHOOL RELATED CHILD CARE EXPENSES FOR THESE CHILDREN: $_______________________per year III. TOTAL INCOME FROM ALL SOURCES, (A, plus B, plus Average of C) PLAINTIFF $__________________________ DEFENDANT $__________________________ A. GROSS YEARLY INCOME FROM EMPLOYMENT DEFENDANT/PETITIONER (2) PLAINTIFF/PETITIONER (1) _______ YES ______ NO ................................................... Employed? ........................................................ ______YES ______NO $ ...... (Actual or Estimate)........Base Yearly Wages........(Actual or Estimate) or Gross Receipts if Self-Employed .......................... Employer .......................... ..................... Payroll Address ..................... .......$ 1 American LegalNet, Inc. www.FormsWorkFlow.com B. ...................... City, State, Zip ...................... OTHER YEARLY INCOME (Please list all sources of other income in Section E.) PLAINTIFF/PETITIONER (1) DEFENDANT/PETITIONER (2) $ $ $ $ $ $ C. Interest/Dividend Income Unemployment Compensation Workers' Security Benefits Compensation, Social or Other Disability Social Security & Pension Income Gross Self-Employment Income Ordinary & Necessary Business Expenses $ $ $ $ $ $ OVERTIME, COMMISSION AND BONUSES EARNED: [Past Three Year History - Year 3 Is Most Recent Year] Overtime, Commission, Bonuses 20_____ Year 1 $_____________________ 20_____ Year 2 $_____________________ 20_____ Year 3 $_____________________ Overtime, Commission, Bonuses 20_____ Year 1 $_____________________ 20_____ Year 2 $_____________________ 20_____ Year 3 $_____________________ D. OTHER INFORMATION CONCERNING CHILDREN: PLAINTIFF/PETITIONER (1) $ per year Court Ordered Child Support Payable for Other Child(ren) Who Are Not of this Marriage Court Ordered Spousal Support Payable to a Spouse(s) Number of Other Minor Child(ren) Living With You (not children of this marriage or step-children) Child Support You Receive for the Minor Child(ren) You Indicated on Line Above DEFENDANT/PETITIONER (2) $ per year $ per year $ per year $ per year $ per year E. 1. OTHER ASSETS AND LUMP SUM INCOME Describe income sources listed in Section B (i.e., retirement/pension benefits, disability income, interests or dividend income, rentals, annuities, etc.) Attach additional pages if needed. Name & Address of Source Identifying Description (Account No., Claim No., Etc.) Income or Benefits 2 American LegalNet, Inc. www.FormsWorkFlow.com 2. Source List any lump sum income (bonus, gifts, inheritance, etc.) in excess of $500, expected to be received within the next six months, not otherwise listed in this affidavit. Attach additional pages if needed. Value $ 3. 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 account ("IRA"), stock option, etc. Attach additional pages if needed. Name(s) on Account Name & Address of Financial Institution Account Number Balance IV. AFFIANT'S MONTHLY EXPENSES List your ACTUAL expenses for your present household. If you expect changes in your expenses soon, attach a separate sheet with your ESTIMATED expenses. If you are living with your parents or someone is helping you with your living expenses, please identify that party _________________________________ and the amount of support provided ____________________. A. MONTHLY EXPENSES 1. Housing Rent or Mortgage (including taxes and insurance) ............................................. $ Utilities a. Gas & Electric (level billing or average per month) ............................... $ b. Water & Sewer ...................................................................................... $ c. Basic Telephone (excluding long distance) ........................................... $ d. Trash Collection: ................................................................................... $ Other: __________________________________________............................ $ HOUSING TOTAL ................................................................................................. $ 2. Other Grocery (include food, laundry & cleaning products/toiletries etc) ............ $ Gasoline & Oil ........................................................................................... $ Car Repairs ............................................................................................... $ Insurance: (life/auto/renter's) ____________________________ ................ $ Medical (not covered by insurance) ..........