IN THE COMMON PLEAS COURT OF SUMMIT COUNTY, OHIO DIVISION OF DOMESTIC RELATIONS _____________________________________ Petitioner (1) Address: ______________________________ ______________________________ Attorney CASE NO. SETS NO. JUDGE _______________________ _______________________ _______________________ ____________________________ ___________________________ MAGISTRATE_______________________ Attorney Address Attorney telephone ___________________________________ Dissolution V. Affidavit of Property and Income _____________________________________ Petitioner (2) Address: ______________________________ ______________________________ ______________________________ Attorney Address ___________________________ Attorney Attorney telephone ___________________________________ Date of Marriage Date of Separation Note: In accordance with Local Rule 2.02, this affidavit must be filed with every dissolution. You are under a continuing legal duty to file an updated version of this form if you learn of any additional information. If more space is needed, attach additional page(s). I. Children: Minor or Dependent Children of this Marriage (Include adopted children and any child of the parties who is over 18 and handicapped) Child's Name Date of Birth Male / Female Age Residing with II. Affidavit of Property: List ALL YOUR PROPERTY AND DEBTS, those of your spouse, and joint property and debts. Do not leave any category blank. For each item, if none, put "NONE." If more space is needed, attach extra pages. A. Real Estate Interests: Address A. B. Titled to Wife, Husband, or Both Present Fair Market Value Mortgages: Balance Due Monthly Payment Page 1 American LegalNet, Inc. www.FormsWorkFlow.com B. Other Assets: Category A. Vehicles 1. 2. 3. 4. B. Financial Accounts 1. 2. 3. C. Pensions & Retirement Plans 1. 2. 3. D. Publicly Held Stocks, Bonds, Securities, & Mutual Funds 1. 2. E. Closely Held Stocks & Other Business Interests 1. 2. F. Life Insurance 1. 2. G. Furniture & Appliances 1. In Your Possession 2. In Spouse's Possession H. Safe Deposit Box (Give location and describe contents) (Estimate value of those in your possession, and value of those in your spouse's possession.) (Include insurance provided by employer, term, whole life, any cash value or loans.) (Describe type of business and type of ownership.) (Include profit-sharing, IRAs, 401(k) plans, etc. Describe each type of plan.) (Include checking, savings, CDs, POD accounts, money market accounts, etc.) Description (Also list who has possession) (Include automobiles, trucks, motorcycles, boats, motors, motor homes, etc.) Titled to Wife, Husband, or Both Present Fair Market Value Balance Due I. All Other Assets (Include collections, rare books, stamps, guns, antiques, art objects, computers, machinery, personal injury/workers compensation claims, promissory notes, loans to others, tax refunds due, interests in estates or trusts, franchises, copyrights, etc.) 1. 2. 3. Page 2 American LegalNet, Inc. www.FormsWorkFlow.com III. Affidavit of Income [As defined in R.C. 3119.01]: A. Gross Yearly Income from Employment Husband Total Gross Annual Income Employer Payroll Address City, State, Zip Paychecks per year 12 24 26 52 Total Gross Annual Income Employer Payroll Address City, State, Zip Paychecks per year Wife 12 24 26 52 B. Other Income All other income, including but not limited to pension, social security, workers compensation, commissions, royalties, disability benefits, unemployment benefits, rents, dividends, interest, OWF, SSI, food stamps, spousal support received from a prior spouse, etc. Husband Describe Per Year Describe Wife Per Year C. Debts: List ALL YOUR DEBTS, debts of your spouse, and joint debts. Do not leave any category blank. For each item, if none, put "NONE". If you don't know exact figures for any item, give your best estimate, and put "EST." If more space is needed, attach extra pages. Type A. Secured debts (Mortgages, car, etc.) 1. 2. 3. B. Unsecured debts, including credit cards 1. 2. 3. Name of Creditor / Purpose of Debt In name of H, W, or Both Total Debt Due Monthly Payment D. Private Health Insurance Carrier Father Name: Address: Provided through: Name: Address: Mother Employer: __________________ Other Group:________________ Provided through: Employer:_________________ Other Group:______________ OATH OF AFFIANTS I hereby swear or affirm that the information set forth in this Affidavit of Income and Property above is true, complete, and accurate. I understand that falsification of this document may result in a contempt of court finding against me which could result in a jail sentence and fine, and that falsification of this document may also subject me to criminal penalties for perjury (R.C. 2921.22). _____________________________________________ Petitioner (1) Sworn to and subscribed before me this Revised September 12, 2008 I:\Website Forms\Dissolution Affidavit _____________________________________________ Petitioner (2) Day of , . _____________________________________________ Notary Public Page 3 American LegalNet, Inc. www.FormsWorkFlow.com