IN THE COMMON PLEAS COURT OF SUMMIT COUNTY, OHIO DIVISION OF DOMESTIC RELATIONS CASE NO. Plaintiff SETS NO. ___________________ Address JUDGE Marital Residence Yes No Phone: MAGISTRATE Attorney Atty Address Atty Phone vs. Defendant Pre Decree Affidavit of Income, Expenses, And Property of _____________________ (Your Name) Address Marital Residence Yes No Phone: Attorney Date of Marriage Atty Address Date of Separation Atty Phone Note:In accordance with Local Rule 2.02 of this court, this affidavit must be filed and served upon the other party with every complaint for divorce, legal separation and annulment. It must also be filed at the time of the answer or temporary hearing, whichever comes first. 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 of this Marriage (Include adopted children and any child of the parties who is over 18 and handicapped) 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 education-related) Local income taxes paid or rate of tax where you live or work $ or % $ or % Private health insurance cost to you for children (family plan cost less individual plan cost) Total Number of dependents covered by your Insurance 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 (If not known, please estimate. Put “EST” after each estimated figure.) Husband Wife Gross yearly employment income Gross yearly employment income Employer Employer Payroll address Payroll address City, state, zip City, state, zip Check the number of paychecks per year 12 Year-to-date gross income 24 26 Check the number of paychecks per year 52 Through date of Year-to-date gross income 24 26 52 Through date of 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.) Husband Year 3 is Most Recent Year 12 Base Income Wife 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: 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. 3119.01(C) Husband Wife Business receipts Business receipts Ordinary & necessary business expenses Ordinary & necessary business expenses Net business income Net business income Initialed Financial Disclosure Affidavit Page 3 American LegalNet, Inc. www.FormsWorkFlow.com 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.) Husband Describe Wife Per Year Describe Per Year E. Total Annual Income Husband Wife 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.) Husband Wife Benefits Values Benefits Initialed Values Financial Disclosure Affidavit Page 4 American LegalNet, Inc. www.FormsWorkFlow.com IV. Affiant's Monthly Living Expenses List your ACTUAL expenses for your present household. 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. 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. There are now present household. A. Housing adults and The reason I expect my household living expenses to change soon is: Actual or Anticipated I am assisted with my living expenses by: B. Other Necessary Living Expenses children living in my Actual or Anticipated (Circle One) Rent (Circle One) FOOD, ETC.: Grocery (include food, paper & cleaning products, toiletries, etc.) First mortgage Real estate taxes (if not included above) Restaurant Real estate insurance (if not included above) TRANSPORTATION, ETC. Car loan or lease Second mortgage, if any Gasoline UTILITIES: Electric (level billing or avg/month) Car maintenance & repair Gas (if billed separately) Parking, public transit CLOTHING, ETC.: Clothes Fuel oil/propane Water & sewer Dry cleaning, laundry PERSONAL GROOMING Telephone: house Telephone: cell Other: Water softener Trash collection Cable television Home cleaning, maintenance, repair Lawn service, snow removal Other: Housing total (A) Initialed Other necessaries total (B) Financial Disclosure Affidavit Page 5 American LegalNet, Inc. www.FormsWorkFlow.com C. Child-Related Expenses Actual or Anticipated (Circle One) D. Education Expenses Actual or Anticipated (Circle One) Child care, work-or education-related You Clothing Tuition School lunches Child(ren) Books, fees, etc. Children’s allowances College loan repayment Extra-curricular activities, lessons Other: Other: Child-related expenses total E. Medical Expenses (Out-of-pocket) for (C) You Education total Child(ren) (D) F. Insurance Actual or Anticipated (Circle One) Doctor Life Dentist Auto Optical Health Orthodontist Disability Prescriptions Renters/personal property, other Other: Other: Medical total G. Enrichment (Your expenses. Put child(ren)’s expenses under C or D, above) (E) Actual or Anticipated Miscellaneous (F) H. Miscellaneous Expenses (Include (Circle One) Actual or Anticipated expenses and debt payments not previously listed.) Entertainment 1. Lessons, sports clubs, hobbies (Circle One) 2. 3. Books, newspapers, magazines Donations 4. Gifts 5. Vacation, other 6. Enrichment total (G) Miscellaneous (H) ACTUAL or ANTICIPATED ( Circle One) *Grand total of monthly expenses (A - H each column) * It is very important that you add each section and put a total on these forms. Initialed Financial Disclosure Affidavit Page 6 American LegalNet, Inc. www.FormsWorkFlow.com V. 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 you don’t know exact figures for any item, give your best estimate, and put “EST”. If more space is needed, attach extra pages. Real Estate Interests: Address Titled to Husband, Wife, or Both Present Fair Market Value Mortgages: Balance Due Monthly Mortgage Payments Titled to Husband, Wife, or Both Present Fair Market Value (Also list A. B. C. D. Other Assets: Category A. Vehicles Description (Also list who has possession) balance due on any liens) (Include automobiles, trucks, motorcycles, boats, motor homes, etc.) 1. 2. 3. B. Financial Accounts (Include checking, savings, CDs, POD accounts, money market accounts, etc.) 1. 2. 3. 4. C. Pensions & Retirement Plans (Include profit-sharing, IRAs, 401K plans, etc. Describe each type of plan.) 1. 2. 3. D. Publicly Held Stocks, Bonds, Securities, & Mutual Funds 1. 2. 3. 4. Initialed Financial Disclosure Affidavit Page 7 American LegalNet, Inc. www.FormsWorkFlow.com E. Closely Held Stocks & Other Business Interests (Describe type of business and type of ownership.) Titled to Husband, Wife, or Both Present Fair Market Value /Balance on liens 1. 2. 3. 4. F. Life Insurance (Include insurance provided by employer, term, whole life, any cash value or loans.) 1. 2. G. Furniture & Appliances (Estimate value of those in your possession, and value of those in your spouse’s possession.) 1. In your possession 2. In spouse’s possession H. Safe Deposit Box I. All Other Assets (Give location and describe contents) (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. J. Transfer of Assets List the name and address of any person [other than creditors listed on your affidavit] who has received money or property from you exceeding $100 in value in the past 12 months and the reason for each transfer. 1. 2. K. Lost Assets List any item you claim is lost or missing as of this date and its value. 1. 2. Initialed Financial Disclosure Affidavit Page 8 American LegalNet, Inc. www.FormsWorkFlow.com VI. 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. Name of Creditor / Purpose of Debt Total Debt Due Monthly Payment Secured debts (Mortgages, car, etc.) 1. 2. 3. 4. 5. 6. B. Unsecured debts, including credit cards 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Bankruptcy: Filed by: Wife Husband, Both Date of Filing: Case Number Date of Discharge or Relief from Stay Type of Case (Ch. 7, 11, 12, 13) Current Monthly Payments 1. 2. Initialed Financial Disclosure Affidavit Page 9 American LegalNet, Inc. www.FormsWorkFlow.com VII. Separate Property Claims: [As defined in O.R.C. 3105.171(6)(A)] If you are making any claims in any of the categories below, check “Yes” for that category and explain the nature and amount of your claim. Category: [Check Yes or No] Yes No Description Particulars leading to your claim of separate ownership Present Fair Market Value Present Debt Inheritances $ $ Property owned before marriage $ $ Passive income and appreciation from separate property $ $ Property acquired after a decree of legal separation $ $ Prenuptial agreement $ $ Personal injury compensation (except loss of marital earnings) $ $ Gifts made solely to one spouse $ $ Initialed Financial Disclosure Affidavit Page 10 American LegalNet, Inc. www.FormsWorkFlow.com VIII. 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 _______________________________ _________________________________ _________________________________ _______________________________ _________________________________ _________________________________ _______________________________ _________________________________ _________________________________ _______________________________ _________________________________ _________________________________ 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: (month/day/year) ____/____/______. Provided through: Employer Current Spouse 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: _____________________ Initialed Financial Disclosure Affidavit Page 11 American LegalNet, Inc. www.FormsWorkFlow.com 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. farther than 30 miles, but 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. farther than 30 miles and 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). 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 _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ 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 January 21, 2010 I:\Website Forms\PREDEC FINAL Initialed Financial Disclosure Affidavit Page 12 American LegalNet, Inc. www.FormsWorkFlow.com