IN THE COURT OF COMMON PLEAS



IN THE COURT OF COMMON PLEASDOMESTIC RELATIONS DIVISIONMEDINA COUNTY, OHIO FORMTEXT ?????)CASE NO. FORMTEXT ?????Plaintiff))JUDGE MARY KOVACK)vs.)AFFIDAVIT IN SUPPORT OF)MOTION FOR TEMPORARY )SPOUSAL SUPPORT, CHILD FORMTEXT ?????)SUPPORT AND/OR CUSTODYDefendant)PURSUANT TO CIV.R. 75(N)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).Now comes FORMCHECKBOX Plaintiff / FORMCHECKBOX Defendant [select one] and states as follows:GENERAL INFORMATION1.I am FORMTEXT ?????years old.2.My current residential address is: FORMTEXT ?????.My FORMCHECKBOX rent / FORMCHECKBOX mortgage is: FORMTEXT ?????per month.My spouse FORMCHECKBOX is / FORMCHECKBOX is not living at this address.3.Names and ages of minor children of this marriage: FORMTEXT ????? FORMTEXT ?????.4.Children reside with whom and where: FORMTEXT ?????.5.I am employed by: FORMTEXT ?????.My employer’s address is: FORMTEXT ?????.My gross pay is :$ FORMTEXT ?????per FORMTEXT ?????[pay period].Sources and amounts of other income, if any: FORMTEXT ?????.6.My Social Security Number is: FORMTEXT ?????.7.My birthdate is: FORMTEXT ?????[month, day, year].8.My spouse is employed by: FORMTEXT ?????.His/her employer’s address is: FORMTEXT ?????.My spouse’s gross pay is: FORMTEXT ?????per FORMTEXT ?????[pay period].Sources and amounts of other income, if any: FORMTEXT ?????.INCOME OF FORMCHECKBOX PLAINTIFF / FORMCHECKBOX DEFENDANT [select one]I am FORMCHECKBOX Full-time / FORMCHECKBOX Part-time [check one].I am employed by: FORMTEXT ?????My employer’s address is: FORMTEXT ?????My gross pay is: $ FORMTEXT ?????per FORMTEXT ?????[e.g., bi-weekly, bi-monthly].Other source(s) and amount(s) of income, if any, FORMTEXT ?????Deductions(per pay period)Amount of DeductionFrequency of Deductions(e.g., per pay, per month)Federal Income Taxes$ FORMTEXT ????? FORMTEXT ?????State Income Taxes$ FORMTEXT ????? FORMTEXT ?????Local Income Taxes$ FORMTEXT ????? FORMTEXT ?????Medical Insurance$ FORMTEXT ????? FORMTEXT ?????Dental Insurance$ FORMTEXT ????? FORMTEXT ?????Life Insurance$ FORMTEXT ????? FORMTEXT ?????Social Security$ FORMTEXT ????? FORMTEXT ?????Medicare$ FORMTEXT ????? FORMTEXT ?????Pension, 401k or other retirement$ FORMTEXT ????? FORMTEXT ?????Union Dues$ FORMTEXT ????? FORMTEXT ?????Other [savings, loans, 401k repay, etc.]$ FORMTEXT ????? FORMTEXT ?????Net Wages from Employment:$ FORMTEXT ?????Other IncomeAmountFood Stamps/Other Assistance$ FORMTEXT ?????Social Security/SSI/SSDI$ FORMTEXT ?????Ohio Works First$ FORMTEXT ?????Medicaid$ FORMTEXT ?????Net Other Income:$ FORMTEXT ?????EXPENSES OF FORMCHECKBOX PLAINTIFF / FORMCHECKBOX DEFENDANT [select one]Please provide average monthly expenses for yourself, and for your children, but if only if you are the residential parent. If you are not the residential parent and not living at the family home, please provide expenses for yourself only. Please state names and relationship of all members of the household whose expenses are included: FORMTEXT ????? FORMTEXT ?????ItemMonthly AmountFOOD and miscellaneous non-food items purchased with groceries$ FORMTEXT ?????2. SHELTER FORMCHECKBOX Mortgage / FORMCHECKBOX Rent $ FORMTEXT ?????Real Estate Taxes [if not escrowed in mortgage payment]$ FORMTEXT ?????Home Insurance [if not escrowed in mortgage payment]$ FORMTEXT ?????Electricity$ FORMTEXT ?????Heat$ FORMTEXT ?????Water$ FORMTEXT ?????Telephone$ FORMTEXT ?????Repairs, maintenance, etc.$ FORMTEXT ?????Water Softener$ FORMTEXT ?????Trash Collection$ FORMTEXT ?????Cable Television$ FORMTEXT ?????Lawn service/snow removal$ FORMTEXT ?????3. AUTOMOBILE AND TRANSPORTATION Car Loan or Lease Payment$ FORMTEXT ?????Gasoline$ FORMTEXT ?????Repairs$ FORMTEXT ?????Automobile Insurance$ FORMTEXT ?????Public Transportation$ FORMTEXT ?????PERSONAL INSURANCE [not otherwise deducted from wages]Health$ FORMTEXT ?????Dental$ FORMTEXT ?????Life$ FORMTEXT ?????Accident and Disability$ FORMTEXT ?????Unreimbursed medical expenses$ FORMTEXT ?????5. CLOTHING, ETC.Clothes$ FORMTEXT ?????Dry cleaning/laundry$ FORMTEXT ?????Haircuts/personal grooming$ FORMTEXT ?????6. CHILD-RELATED EXPENSESChild care, work or education related$ FORMTEXT ?????School lunches$ FORMTEXT ?????Children’s Allowances$ FORMTEXT ?????Lessons$ FORMTEXT ?????Extra-Curricular Activities$ FORMTEXT ?????Other [specify]: FORMTEXT ?????$ FORMTEXT ?????7. MISCELLANEOUSBooks, newspapers, magazines$ FORMTEXT ?????Gifts$ FORMTEXT ?????Vacation$ FORMTEXT ?????Extraordinary pet expenses$ FORMTEXT ?????Donations$ FORMTEXT ?????Entertainment$ FORMTEXT ?????Other [specify]: FORMTEXT ?????$ FORMTEXT ?????8. PRE-EXISTING COURT-ORDERED SUPPORT FROM PRIOR CASE(S):Child Support$ FORMTEXT ?????Spousal Support$ FORMTEXT ?????Net Total Expenses:$ FORMTEXT ?????Installment obligations, other than mortgage, i.e., finance companies, department stores, credit cards, medical, hospital debts: If additional space is needed, use the back of this form. Indicate whether “Husband,” “Wife,” or “Joint.”CreditorAmount owedMonthly PaymentDebtor 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 ?????Net Total:$ FORMTEXT ?????$ FORMTEXT ?????This information is, to the best of my knowledge, true and complete based upon information given to me by my client and through discovery, if any, and may be admitted into evidence upon trial of this case.Counsel for FORMCHECKBOX Plaintiff FORMCHECKBOX DefendantOATH(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.Signature FORMCHECKBOX Plaintiff FORMCHECKBOX DefendantSworn before me and signed in my presence on FORMTEXT ?????,20 FORMTEXT ?????.Notary PublicMy Commission Expires: ................
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