In the Court of Common Pleas General Trial Division Tuscarawas County, Ohio Name:______________________________________ Address:____________________________________ ___________________________________________ SS#:_______________________________________ DOB:______________________________________ Telephone #:_________________________________ Driver=s License #:____________________________ Petitioner, -and- : : : Judge_________________________________ : : Case No.______________________________ : : : : Name:______________________________________ Address:____________________________________ ___________________________________________ SS#:_______________________________________ DOB:______________________________________ Telephone #:_________________________________ Driver=s License #:____________________________ Petitioner, : Child Support Worksheet : : Financial Affidavit - Wife : : : : : I, _______________________ Petitioner, Wife,_________________________, 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. I earn $_____________________ per hour/per week/per month. (circle one) 3. I work an average of ___________________ hours per week. 4. I receive unemployment compensation of $____________________ per week/per month. (circle one) 5. I receive workers= compensation or disability insurance benefits of $________________________ per week/per month. (circle one) 6. I received other income in the amount of $___________________ per month/per year. (circle one) Page 1 of 2 American LegalNet, Inc. www.USCourtForms.com I receive this income from: __________________________________________________________. (List source, including self-employment income if applicable) 7. My gross income for last year was $_____________________________. 8. My year-to-date gross income for this year is $_____________________, through ______________. (date) 9. I do/do not have health insurance available for the minor child(ren). (circle one) The insurance costs $______________ per week/per month. (circle one) A) The cost to cover myself only is $______________________ per week/per month. (circle one) B) The extra cost to cover the child(ren) is $______________________ per week/per month. (circle one) 10. I pay work-related/education-related/employment-training-related/day care expenses for the minor child(ren) of this marriage in the amount of $_______________ per week/per month. (circle one) 11. I am the biological parent of ________________________ other minor child(ren) who live in my (number of children) home. I receive $_________________ per month in court-ordered child support for these other minor biological child(ren). 12. I pay _____________ percent city income tax. 13. I pay union dues in the amount of $_____________. 14. I pay $______________________ per month in court-ordered spousal support to my ex-husband. 15. I pay $______________________ per month in court-ordered child support for another child(ren). 16. A Shared Parenting Plan is/is not attached to the Petition that has been filed with the Court. (circle one) _________________________________________ Signature of Petitioner Wife Sworn to and subscribed in my presence this ________ day of ___________________, ____________. _________________________________________ Notary Public Page 2 of 2 American LegalNet, Inc. www.USCourtForms.com