IN THE COMMOM PLEAS COURT OF SUMMIT COUNTY, OHIO DIVISION OF DOMESTIC RELATIONS _____________________________________ Plaintiff / Petitioner (1) CASE NO. _______________________ MOTION NO. _______________________ Address: ______________________________ ______________________________ SETS NO. JUDGE Phone: _______________________ Attorney ____________________________ Attorney Address _______________________ _______________________ MAGISTRATE _______________________ ___________________________ Attorney telephone ___________________________________ V. Post Decree or Parentage Financial Affidavit of _____________________________________ Defendant / Petitioner (2) / Respondent ___________________________ (Your Name) Address: ______________________________ ______________________________ Date of Prior Decree Phone: _______________________ ____________________________ Attorney Address ___________________________ Attorney Attorney telephone ___________________________________ Notes: In accordance with Local Rules 2.02(B) & 2.07 of this court, this affidavit must be filed by each party with every postdecree motion or parentage case that concerns support. You will be required to provide proof of income per local rule and O.R.C. 3119.05. 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. Information Required for Support Calculation: A. Minor or Dependent Children in This Case (Include adopted children and any child of the parties who is over 18 and handicapped) Child’s Name Date of Birth Male / Female Initialed Age Residing with Financial Disclosure Affidavit Page 1 American LegalNet, Inc. www.FormsWorkflow.com B. Other Minor Children Living in My Household Child’s Name Date of Birth Male / Female Age Relationship Age Residing with C. Other Minor Children of Mine, Not Living in My Household Child’s Name Date of Birth Male / Female II. Child Support Guideline Adjustment: Father (All Figures Per Year) Mother (All Figures Per Year) Court ordered child support you pay for other child(ren) in another case Case Number where support ordered Date of initial order Court ordered spousal support you pay to a former spouse Number of your other dependent children living with you from a different marriage or relationship Is the other parent of any of your other children also in your household? Yes No Yes No If yes, how many children do you have with the parent who lives with you? Court ordered child support you receive for the dependent child(ren) you indicated on line above (other parent not in home) Child care expenses you pay for child(ren) of this case (employment or educational-related) Local income taxes paid or rate of tax where you live or work $ or % $ or % Self-Employment Tax (5.6% of A.G.I.) Private health insurance cost to you for children (family plan cost less individual plan cost) Total number of dependents covered by your insurance Current partner’s gross income Initialed Financial Disclosure Affidavit Page 2 American LegalNet, Inc. www.FormsWorkflow.com III. Income [As defined in O.R.C. 3119.01(C)]: A. Gross Yearly Income from Employment Father (If not known, please estimate. Put “EST” after each estimated figure.) Mother Gross yearly employment income Gross yearly employment income Employer Employer Payroll Address Payroll Address City, State, Zip City, State, Zip Number of paychecks per year 12 24 26 Check the number of Paychecks per year 52 Through date of Year-to-date Gross Income 24 26 52 Through date of Year-to-date Gross Income Prior Year’s Tax Refund Prior Year’s Tax Refund B. Annual Overtime, Commissions, Bonuses (If not known, please estimate. Put “EST” after each estimated figure.) Father Year 3 is Most Recent Year 12 Base Income Mother Overtime, commission, Bonuses Year 3 is Most Recent Year _____ Year 1 _____ Year 2 _____ Year 3 _____ Year 3 Y-T-D This Year Through: Overtime, commission, Bonuses _____ Year 1 _____ Year 2 Base Income Y-T-D This Year Through: D. 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. 3119.01(C) Father Mother Business Receipts Business Receipts Ordinary & Necessary Business Expenses Ordinary & Necessary Business Expenses Net Business Income Net Business Income D. 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.) Father Describe Mother Per Year Describe Initialed Per Year Financial Disclosure Affidavit Page 3 American LegalNet, Inc. www.FormsWorkflow.com E. Total Annual Income Father Mother Total gross annual income Total gross annual income Total average gross monthly income Average monthly deductions Total net monthly income Total average gross monthly income ÷ 12 = Less ÷ 12 = Average monthly deductions Less Total net monthly income = = F. Benefits of Employment (Use of company car, country club memberships, stock options, etc.) Father Benefits Mother Values Benefits Values IV. Private Health Insurance Information CHECK ALL APPLICABLE BOXES AND FILL-IN ALL BLANKS. My child(ren is/are covered by low-income government –assisted health care coverage (Healthy Start/Medicaid, etc.) LIST OF PLANS I have the following private health insurance policies, contracts or plans to cover the child(ren) available to me. Name of policy, contract or plan Name of Insurance Company Entity/group through which policy, contract or plan is available _______________________________ _________________________________ _________________________________ _______________________________ _________________________________ _________________________________ _______________________________ _________________________________ _________________________________ _______________________________ _________________________________ _________________________________ Initialed Financial Disclosure Affidavit Page 4 American LegalNet, Inc. www.FormsWorkflow.com NO PRIVATE HEALTH INSURANCE I DO NOT HAVE the child(ren) enrolled in private health insurance because: health insurance is not available through my employer or another group policy, contract or plan that will cover the children. I declined enrollment of the child(ren) in health insurance available through my employer or another group policy, contract or plan, but I am enrolled in a policy, contract or plan for myself. I am not yet eligible to enroll in private health insurance through employment or another group policy, contract or plan, but I will become eligible on (month/day/year) ____/____/______. I expect to enroll the child(ren) when I become eligible. OTHER reason the child(ren) is/are not enrolled (explain): ___________________________________________________ CURRENT PRIVATE HEALTH INSURANCE ENROLLMENT I DO HAVE the child(ren) enrolled in private health insurance through: an individual (non-group) policy, contract or plan. a group policy, contract or plan. Date child(ren) was/were enrolled in private health insurance: Provided through: Employer Current Spouse (month/day/year) ____/____/______. Other: ____________________________________________________________ Name of Policyholder: ____________________________ Insurance Co. Name: ____________________________ Policyholder address: ____________________________ Ins. Co. Claims address ____________________________ __________________________________________________ _________________________________________________ Policyholder Phone No. (___) _______________________ Ins. Co. Claims Phone No. (____) _____________________ Name of policy, contract or plan _______________________ Group Number: ___________________________ Identification/subscriber Number: _____________________ ACCESSIBILITY OF PRIMARY CARE SERVICE My child(ren) has/have primary care services (health care/laboratory services customarily provided by a general practitioner, internal medicine, family medicine physician, or pediatrician) accessible with this private health insurance: within 30 miles of the child(ren)’s home. because the child(ren) live(s) in a geographic area where the residents customarily travel farther than 30 miles for their child(ren)’s primary care services. because primary care services are only accessible by public transportation. (Primary care services are accessible by public transportation and the person responsible for taking the child(ren) for primary care service is dependent upon public transportation). Initialed Financial Disclosure Affidavit Page 5 American LegalNet, Inc. www.FormsWorkflow.com REASONABLENESS OF COST/BEST INTEREST OF CHILDREN CONSIDERATIONS The cost for private health insurance benefits that cover me and/or my child(ren) or will cover us when I am eligible is: (Do not include the amount than an employer or other person/entity pays for health insurance.) Single coverage Single coverage plus one Single coverage plus two Family coverage (unlimited dependents) Other (explain): __________________________ $_______________ per month $_______________ per month $_______________ per month $_______________ per month $_______________ per month I want to enroll/continue to have the child(ren) enrolled in the private health insurance plan in which I am currently enrolled/will become eligible to enroll in even if the cost exceeds 5% of my TOTAL ANNUAL GROSS INCOME (Health Insurance Maximum). Number of Dependents currently enrolled or who will be enrolled when I become eligible: _________ Name of Dependent ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ Relationship to You _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ V. List any additional factors or special circumstances you believe the court should consider. ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ OATH OF AFFIANT I, (print) hereby swear or affirm that the information set forth in this Affidavit of Income, Expenses, 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 (O.R.C. 2921.22). AFFIANT Sworn to and subscribed before me this Day of , . Notary Public Revised October 3, 2008 I:\Website Forms\POSTdecree final Initialed Financial Disclosure Affidavit Page 6 American LegalNet, Inc. www.FormsWorkflow.com