In the Court of Common Pleas Tuscarawas County, Ohio General Trial Division Name:_____________________________________ Address:___________________________________ ___________________________________________ Phone:_____________________________________ Petitioner 1, and Name:_____________________________________ Address:___________________________________ ___________________________________________ Phone:_____________________________________ Petitioner 2. : : : : : : Judge________________________________ Case No._____________________________ : : Petitioner 1 : Financial Affidavit : : : I, _______________________ , state under oath that the following information is complete and accurate to the best of my information, knowledge and belief: 1. I am employed at ___________________________________________________________. (include name and address) 2. My annual gross income is ______________________. I earn $_____________________ per hour per week per month and have _______ pay periods per year. (number) 3. 4. I earn overtime, bonuses, and/or commissions, and they have been as follows: $__________ 3 years ago $__________ 2 years ago $__________ last year $__________ average of above 5. I am selfemployed and below is my income/expense information: a. $_______________ gross receipts from business b. $_______________ ordinary and necessary business expenses c. $_______________ 5.6% of adjusted gross income or actual marginal difference between the actual rate paid by me and the F.I.C.A. rate Page 1 of 2 Petitioner 1 Financial Affidavit American LegalNet, Inc. www.FormsWorkFlow.com Revised 2/12/2016  6. 7. d. $_______________ adjusted gross income (subtract the sum of b. and c. from a.) $__________ is my annual income from interest and dividends. I receive unemployment compensation of $__________________ per week per month. I received unemployment compensation earlier this calendar year in the amount of $__________. 8. 9. 10. 11. 12. 13. I receive workers' compensation, disability insurance benefits, or social security disability/retirement benefits of $____________________ per week per month. I am the biological or adoptive parent of ______ (number) of other minor child(ren) who live in my home and are not the children of my current spouse. I receive $_________________ per month in courtordered child support for these other minor child(ren). I pay courtordered spousal support in the amount of $__________ per year to my former spouse. I pay _____________ in local income taxes in the amount of $__________ per year. This is at a rate of _____% and it is paid to _____________________ (name of city/tax district). I have mandatory workrelated deductions such as union dues, uniform fees, etc. (not including taxes, social security or retirement) that total $__________ per year. I pay workrelated, educationrelated, employmenttrainingrelated and/or day care expenses for the minor child(ren) of this marriage in the amount of $_______________ per year. I pay outofpocket costs necessary to provide health insurance for my child(ren) from this marriage in the amount of $__________ per year. a. The cost to cover myself only is $_______________ per week per pay. 14. b. The family plan is $_______________ per week per pay. _________________________________________ Signature of Petitioner 1 Sworn to and subscribed in my presence this ________ day of _______________, 20_______. _________________________________________ Notary Public Revised 2/12/2016 Page 2 of 2 Petitioner 1 Financial Affidavit American LegalNet, Inc. www.FormsWorkFlow.com