9/8/99 modifiedAFD/AFDD/AFDO DR-10.aIN THE COMMON PLEAS COURT OF MONTGOMERY COUNTY, OHIO DIVISION OF DOMESTIC RELATIONSCase No.Plaintiff/Petitioner(1):DOB AddressJUDGE :V.Affidavit of Income, Expenses and Property of(Name):(NEW CASES)Defendant/Petitioner(2)Date of MarriageDOB AddressDate of SeparationTemporary Orders RequestedOther Cases custody / visitationDV Bankruptcy child supportJuvenile UIFSA spousal supportNotes: This affidavit must be filed and served in accordance with Local Rules of Court in every action for divorce, dissolution, legal separation, and annulment. You will be required to provide proof of income per local rule and O.R.C. 3113.215(B)(5). You are under a continuing legal duty to file an updated version of this form if you learn of anyadditional information. If more space is needed, attach additional page(s).I. Income [As defined in O.R.C. 3113.215(A)]: A. Gross Yearly Income from Employment (If not known, please estimate. Put EST after each estimated figure.)Wife / MotherHusband / FatherGross Yearly Employment Income EmployerPayroll Address City, State, Zip Check the number of Paychecks per year 12 24 26 52 12 24 26 52Year-to-date Gross IncomeThrough date ofThrough date ofPrior Year's Tax RefundFinancial Disclosure Affidavit Page 1Initialed2001 © American LegalNet, Inc.B. Annual Overtime, Commissions, Bonuses(If not known, please estimate. Put EST after each estimated figure.)Husband / FatherWife / Mother Year 3 is Most Recent YearOvertime,Commission,BonusesYear 3 is Most Recent YearOvertime,Commission,BonusesBase IncomeBase Income19Year 119Year 119Year 219Year 219Year 319Year 3Y-T-D This Year Through:Y-T-D This Year Through:C. Gross Self-Employment Income (If not known, please estimate. Put EST after each estimated figure.)Use Gross Annual Figures for Most Recent Full Year. See O.R.C. 3113.215(A)Husband / FatherWife / MotherBusiness Receipts Ordinary & Necessary Business Expenses Net Business IncomeD.Other Income All other income, actual or expected, including pension, social security, workers compensation, commissions, royalties, disability benefits, trust income, annuities, reoccurring capital gains, unemployment benefits, rents, expense-sharing, dividends, interest, AFDC, SSI, food stamps, spousal support received from a prior spouse, etc. (If not known, please estimate. Put EST after each estimated figure.)Husband / FatherWife / MotherDescribeDescribePer YearPer YearFinancial Disclosure Affidavit Page 2Initialed2001 © American LegalNet, Inc.E. Total Annual IncomeHusband / FatherWife / MotherTotal gross annual incomeTotal gross annual incomeTotal average gross monthly incomeTotal average gross monthly income÷ 12 =÷ 12 =Average monthly deductionsLessAverage monthly deductionsLessTotal net monthly income=Total net monthly income=F. Benefits of Employment (Use of company car, country club memberships, stock options, etc.)Husband / FatherWife / MotherBenefitsValuesBenefitsValuesII. Information Required for Support Calculation: A. Minor or Dependent Children of this Marriage(Include adopted children and any child of the parties who is over 18 and handicapped)Child's NameDate of BirthResiding withB. Other Minor Children Living in My HouseholdChild's NameRelationshipDate of BirthC. Other Minor Children of Mine, Not Living in My HouseholdChild's nameResiding withDate of BirthFinancial Disclosure Affidavit Page 3Initialed2001 © American LegalNet, Inc.III. Child Support Guideline Adjustment:Husband/Father (All Figures Per Year)Wife/Mother (All Figures Per Year)Court Ordered Child Support You Pay for Other Child(ren) in Another Case Court Ordered Spousal Support You Pay to a Former Spouse Number of Your Other Dependent Children Living With You From a Previous Marriage or Relationship Court Ordered Child Support You Receive for the Dependent Child(ren) You Indicated on Line Above Child Care Expenses You Pay for Child(ren) of this Marriage (Employment Or Educational-Related) Local Income Taxes Paid or Rate of Tax where you Live or Workor:%or:%Self-Employment Tax (5.6% of A.G.I.)Health Insurance Premium for Children (Family Plan Cost Less Individual Plan Cost)IV. Affiant's Monthly Living Expenses:List your ACTUAL expenses for your present household in the first column. Give estimated expenses if you don't have exact figures. If you expect changes soon, list your ANTICIPATED expenses in your household after the divorce case in the second column. Explain why you expect your expenses to change. Also, if you are living with your parents or someone is helping you with your living expenses, please explain.Anticipated Future Monthly Expenses in My HouseholdMy Average Monthly ExpensesActual Monthly Expenses in My Present HouseholdI am assisted with my living expenses by:The reason I expect my household living expenses to change soon is:There are nowAdults andChildren living in my present household.Financial Disclosure Affidavit Page 4Initialed2001 © American LegalNet, Inc.A. HousingActualAnticipatedRent or First MortgageReal Estate Taxes (if not included above)Real Estate Insurance (if not included above)Second Mortgage, if any UTILITIES:Electric (level billing or avg/month)Gas (if billed separately)Fuel Oil/PropaneWater & SewerTelephone (basic monthly charge)Water SoftenerTrash CollectionTelephone (average long distance)Cable TelevisionHome Cleaning, Maintenance, RepairLawn Service, Snow RemovalOther: Housing Total(A)(A)B. Other Necessary Living ExpensesAnticipatedActualFOOD, ETC.: Grocery (include food, paper & cleaning products, toiletries, etc.) Restaurant TRANSPORTATION, ETC.: Car Loan or Lease Gasoline Car Maintenance & Repair Parking, Public TransitFinancial Disclosure Affidavit Page 5Initialed2001 © American LegalNet, Inc.B. Other Necessary Living Expenses (Con't)ActualAnticipatedCLOTHING, ETC.: Clothes Dry Cleaning, Laundry Personal GroomingOther: Other: (B)(B)Other Necessities TotalC. Child-Related ExpensesActualAnticipatedChild Care, Work-or Educational-RelatedClothingSchool LunchesChildren's AllowancesExtra-Curricular ActivitiesOther: Child-Related Expenses Total(C)(C)AnticipatedActualD. Educational Expenses for:Child(ren)YouChild(ren)YouTuition$Books$Fees$Tutor$Activities$College Loan Repayment$Other: $Education Total$(D)(D)Financial Disclosure Affidavit Page 6Initialed2001 © American LegalNet, Inc.E. Medical Expenses(Out-of-pocket) forYouChild(ren)YouChild(ren)DoctorDentistOpticalOrthodontistPrescriptionsOther: M