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Financial Affidavit-Husband Form. This is a Ohio form and can be use in Tuscarawas County (Court Of Common Pleas).
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Tags: Financial Affidavit-Husband, Ohio County (Court Of Common Pleas), Tuscarawas
In the Court of Common Ple as
Ge ne ral Trial Divis ion
Tus carawas County, Ohio
Na me :
Addre s s :
J udge
S S #:
DOB:
Te le phone #:
Drive r's Lice ns e #:
P e titione r,
Ca s e No.
-a ndNa me :
Addre s s :
Child S upport Works he e t
Financial Affidavit -Hus band
S S #:
DOB:
Te le phone #:
Drive r's Lice ns e #:
P e titione r,
P e titione r Hus ba nd,
, s ta te unde r oa th tha t
I,
the following informa tion is comple te a nd a ccura te to the be s t of my informa tion, knowle dge a nd be lie f:
1. I a m e mploye d a t
(include na me a nd a ddre s s )
2. I e a rn $
pe r hour/pe r we e k/pe r month.
(circle one)
3. I work a n a ve ra ge of
hours pe r we e k.
4. I re ce ive une mployme nt compe ns a tion of $
pe r we e k/pe r month.
(circle one)
5. I re ce ive worke rs ' compe ns a tion or dis a bility ins ura nce be ne fits of $
pe r we e k/pe r month.
(circle one)
6. I re ce ive d othe r income in the a mount of $
pe r month/pe r ye ar.
(circle one)
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I re ce ive this income from:
(Lis t s ource , including s e lf-e mployme nt income if a pplica ble )
7. My gros s income for la s t ye a r wa s $
8. My ye a r-to-da te gros s income for this ye a r is $
, through
(date)
9. 1 do/do not ha ve he a lth ins ura nce a va ila ble for the minor child(re n).
(circle one)
The ins ura nce cos ts $
pe r we e k/pe r month.
(circle one)
A) The cos t to cove r mys e lf only is $
pe r we e k/pe r month.
(circle one)
B) The e xtra cos t to cove r the child(re n) is $
pe r we e k/pe r month.
(circle one)
I 0. I pa y work-re la te d/e duca tion-re la te d/e mployme nt-tra ining-re la te d/da y ca re e xpe ns e s for the
pe r we e k/pe r month.
minor child(re n) of this ma rria ge in the a mount of $
(circle one)
othe r minor child(re n) who live in my
I 1. I a m the biologica l pa re nt of
(numbe r of childre n)
pe r month in court-orde re d child s upport for the s e othe r
home . I re ce ive $
minor biologica l child(re n).
12. I pa y
pe rce nt city income ta x.
13. 1 pa y union due s in the a mount of $
14. I pa y $
pe r month in court-orde re d s pous a l s upport to my e x-wife .
15. I pa y $
pe r month in court-orde re d child s upport for a nothe r child(re n).
16. A S ha re d P a re nting P la n is /is not a tta che d to the P e tition tha t ha s be e n file d with the Court.
(circle one)
S igna ture of P e titione r Hus ba nd
S worn to a nd s ubs cribe d in my pre s e nce this
da y of
20
Nota ry P ublic
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