Affidavit re Income and Expenses



IN THE COURT OF COMMON PLEASDOMESTIC RELATIONS DIVISIONMEDINA COUNTY, OHIO FORMTEXT ?????)CASE NO. FORMTEXT ?????Plaintiff))vs.)JUDGE MARY KOVACK) FORMTEXT ?????)Defendant)NOTE: This document should not be filed with the Clerk of Courts, but should be submitted to the Court’s confidential file, and accompanied by a Notice of Submission (Form 1.10B). Do not leave any category blank. For each item, if none, put “NONE.” If you do not know exact figures for any item, give your best estimate, and put “EST.” If more space is needed, add additional pages.AFFIDAVIT OF INCOME AND EXPENSESAffidavit of FORMTEXT ?????(Print Your Name)Date of marriage FORMTEXT ?????Date of separation FORMTEXT ?????SECTION I – INCOMEYouSpouseEmployed FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoEmployer FORMTEXT ????? FORMTEXT ?????Payroll address FORMTEXT ????? FORMTEXT ?????Payroll city, state, zip FORMTEXT ????? FORMTEXT ?????Scheduled paychecks per year FORMCHECKBOX 12 FORMCHECKBOX 24 FORMCHECKBOX 26 FORMCHECKBOX 52 FORMCHECKBOX 12 FORMCHECKBOX 24 FORMCHECKBOX 26 FORMCHECKBOX 52A.YEARLY INCOME, OVERTIME, COMMISSIONS AND BONUSES FOR PAST THREE YEARSYouSpouseBase yearly income$ FORMTEXT ?????3 years ago 20 FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????2 years ago20 FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Last year 20 FORMTEXT ?????$ FORMTEXT ?????Yearly overtime, commissions and/or bonuses$ FORMTEXT ?????3 years ago 20 FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????2 years ago20 FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Last year 20 FORMTEXT ?????$ FORMTEXT ?????PUTATION OF CURRENT INCOMEYouSpouseBase yearly income$ FORMTEXT ?????$ FORMTEXT ?????Average yearly overtime, commissions and/or bonuses over last 3 years (from part A)$ FORMTEXT ?????$ FORMTEXT ?????Unemployment compensation$ FORMTEXT ?????$ FORMTEXT ?????Disability benefits$ FORMTEXT ?????$ FORMTEXT ????? FORMCHECKBOX Workers’ Compensation FORMCHECKBOX Social Security FORMCHECKBOX Other: FORMTEXT ?????Retirement benefits$ FORMTEXT ?????$ FORMTEXT ????? FORMCHECKBOX Social Security FORMCHECKBOX Other: FORMTEXT ?????Spousal support received$ FORMTEXT ?????$ FORMTEXT ?????Interest and dividend income (source)$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Other income (type and source)$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????TOTAL YEARLY INCOME$ FORMTEXT ?????$ FORMTEXT ?????Supplemental Security Income (SSI) or public assistance$ FORMTEXT ?????$ FORMTEXT ?????Court-ordered child support that you receive for minor and/or dependent child(ren) not of the marriage or relationship$ FORMTEXT ?????$ FORMTEXT ?????SECTION II – CHILDREN AND HOUSEHOLD RESIDENTSMinor and/or dependent child(ren) who are from this marriage or relationship:NameDate of birthLiving with FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????In addition to the above children there is/are in your household: FORMTEXT ?????adult(s) FORMTEXT ?????other minor and/or dependent child(ren).SECTION III – EXPENSESList monthly expenses below for your present household.MONTHLY HOUSING EXPENSESRent or first mortgage (including taxes and insurance)$ FORMTEXT ?????Real estate taxes (if not included above)$ FORMTEXT ?????Real estate/homeowner’s insurance (if not included above)$ FORMTEXT ?????Second mortgage/equity line of credit$ FORMTEXT ?????UtilitiesElectric$ FORMTEXT ?????Gas, fuel oil, propane$ FORMTEXT ?????Water and sewer$ FORMTEXT ?????Telephone$ FORMTEXT ?????Trash collection$ FORMTEXT ?????Cable/satellite television$ FORMTEXT ?????Cleaning, maintenance, repair$ FORMTEXT ?????Lawn service, snow removal$ FORMTEXT ?????Other: FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????TOTAL MONTHLY HOUSING EXPENSES :$ FORMTEXT ?????OTHER MONTHLY LIVING EXPENSESFoodGroceries (including food, paper, cleaning products, toiletries, other)$ FORMTEXT ?????Restaurant$ FORMTEXT ?????TransportationVehicle loans, leases$ FORMTEXT ?????Vehicle maintenance (oil, repair, license)$ FORMTEXT ?????Gasoline$ FORMTEXT ?????Parking, public transportation$ FORMTEXT ?????ClothingClothes (other than children’s)$ FORMTEXT ?????Dry cleaning, laundry$ FORMTEXT ?????Personal groomingHair, nail care$ FORMTEXT ?????Other FORMTEXT ?????$ FORMTEXT ?????Cell phone$ FORMTEXT ?????Internet (if not included elsewhere)$ FORMTEXT ?????Other FORMTEXT ?????$ FORMTEXT ?????TOTAL MONTHLY LIVING EXPENSES: $ FORMTEXT ?????MONTHLY CHILD-RELATED EXPENSES(for children of the marriage or relationship)Work/education-related child care$ FORMTEXT ?????Other child care$ FORMTEXT ?????Unusual parenting time travel$ FORMTEXT ?????Special and unusual needs of child(ren) (not included elsewhere)$ FORMTEXT ?????Clothing$ FORMTEXT ?????School supplies$ FORMTEXT ?????Child(ren)’s allowances$ FORMTEXT ?????Extracurricular activities, lessons$ FORMTEXT ?????School lunches$ FORMTEXT ?????Other FORMTEXT ?????$ FORMTEXT ?????TOTAL MONTHLY CHILD-RELATED EXPENSES: $ FORMTEXT ?????INSURANCE PREMIUMSLife$ FORMTEXT ?????Auto $ FORMTEXT ?????Health$ FORMTEXT ?????Disability$ FORMTEXT ?????Renters/personal property (if not included in part A above)$ FORMTEXT ?????Other FORMTEXT ?????$ FORMTEXT ?????TOTAL MONTHLY INSURANCE PREMIUMS:$ FORMTEXT ?????MONTHLY EDUCATION EXPENSESTuitionSelf$ FORMTEXT ?????Child(ren)$ FORMTEXT ?????Books, fees, other$ FORMTEXT ?????College loan repayment$ FORMTEXT ?????Other FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????TOTAL MONTHLY EDUCATION EXPENSES:$ FORMTEXT ?????MONTHLY HEALTH CARE EXPENSES (not covered by insurance)Physicians$ FORMTEXT ?????Dentists$ FORMTEXT ?????Optometrists/opticians$ FORMTEXT ?????Prescriptions$ FORMTEXT ?????Other FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????TOTAL MONTHLY HEALTH CARE EXPENSES:$ FORMTEXT ?????MISCELLANEOUS MONTHLY EXPENSESExtraordinary obligations for other minor/handicapped child(ren) (not stepchildren)$ FORMTEXT ?????Child support for children who were not born of this marriage or relationship and were not adopted of this marriage$ FORMTEXT ?????Spousal support paid to former spouse(s)$ FORMTEXT ?????Subscriptions, books$ FORMTEXT ?????Entertainment$ FORMTEXT ?????Charitable contributions$ FORMTEXT ?????Memberships (associations, clubs)$ FORMTEXT ?????Travel, vacations$ FORMTEXT ?????Pets $ FORMTEXT ?????Gifts$ FORMTEXT ?????Bankruptcy payments$ FORMTEXT ?????Attorney fees$ FORMTEXT ?????Required deductions from wages (excluding taxes, Social Security and Medicare) (type) FORMTEXT ?????$ FORMTEXT ?????Additional taxes paid (not deducted from wages) (type) FORMTEXT ?????$ FORMTEXT ?????Other FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????TOTAL MONTHLY MISCELLANEOUS EXPENSES:$ FORMTEXT ?????MONTHLY INSTALLMENT PAYMENTS (Do not repeat expenses already listed.)Examples: car, credit card, rent-to-own, cash advance paymentsTo whom paidPurposeBalance dueMonthly payment FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????TOTAL MONTHLY INSTALLMENT PAYMENTS:$ FORMTEXT ?????GRAND TOTAL MONTHLY EXPENSES (Sum of A through H):$ FORMTEXT ?????OATH(Do not sign until notary is present.)I, (print name) FORMTEXT ?????, swear or affirm that I have read thisdocument and, to the best of my knowledge and belief, the facts and information stated in this document are true, accurate and complete. I understand that if I do not tell the truth, I may be subject to penalties for perjury.SignatureSworn before me and signed in my presence this FORMTEXT ?????day of FORMTEXT ?????, FORMTEXT ?????.Notary PublicMy Commission Expires: ................
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