Domestic Relations Financial Affidavit Form

Section 1
Affiant's Name		Age
Social Security Number
Spouse's Name		Age
Date of Marriage		Date of Separation
Names and birth dates of children of this marriage
Name	Date of Birth	Resides with




Names and birth dates of other children residing with Affiant
Name	Date of Birth	Resides with

Gross Monthly Income (from item 3A)
Net Monthly Income (from Item 3C)
Average monthly expenses (from item 5A)
Monthly payments to creditors (item 5B)
Total Monthly Expenses and Payments
Monthly Excess or Shortfall
Non-custodial Parent's Monthly Salary
Amount of Spousal/Child Support Requested by Affiant
Amount of Alimony Requested
Health Insurance Premium for Children
Total Amount Requested
Amount of Child Support,indicated by Child Support Guidelines, for non-custodial Parent
#1 Minimum
#2 Median
#3 Maximum

(All income must be entered based on monthly average regardless of date of receipt. Where applicable, income should be annualized)

Salary
Bonuses, commissions, allowances, overtime, tips and similar payments (based on past 12-month average or time of employment if less than one year) Attach Sheet itemizing this Income
Business income from sources such as self-employment, partnership, close corporations, and/or independent contracts (gross receipts minus ordinary expenses required to produce income)Attach Sheet itemizing this Income

Disability/unemployment/workers' comp.
Pension, retirements or annuity payments
Social Security Benefits
Other public benefits (specify)
Spousal/child support from prior marriage
Interest and Dividends
Rental income (gross receipts minus ordinary and necessary expenses required to produce income.) Attach Sheet itemizing this Income

Income from royalties, trusts, or estates
Gains derived from dealing in property (not including non-recurring gains)
Other income of a recurring nature (specify)
*TOTAL*

List and describe all benefits of employment, e.g., automobile and/or auto allowance, insurance (auto, life, medical, disability, etc.), deferred compensation, employer contribution to retirement or stock club memberships and reimbursed expenses (to the extent they reduce personal living expenses). Attach sheet, if necessary.

(If you claim or agree that all or part of an asset is non-marital, indicate the non-marital portion under the appropriate spouse column). The total value of each asset must be listed in the value column. Value means what you feel the item of property would be worth if it were offered for sale.

*Description*	*Value*	*JointAsset*	*Separate Asset of Husband*	*Separate Asset of Wife*
Cash
Stocks
Bonds
CDs
Money Market Accounts
Real Estate
Home
Other
Automobiles
a.
b.
c.
Money owed you
Retirement/IRA
Husband
Wife
Furniture
Jewelry
Life Insurance(cash value)
Collectibles
Bank Accounts
a.
b.
Other Assets: Attach sheet itemizing other assets
a.
b.
c.
d.
Total Assets

*HOUSEHOLD*
Mortgage or rent payments		Repairs & maintenance
Property taxes		Lawn care
Insurance		Pest control
Electricity		Cable TV
Water		Miscellaneous household items
Garbage & Sewer		Meals outside home
Telephone		Groceries
Gas		Other
*AUTOMOBILE*
Gasoline and Oil		Auto tags & License
Repairs		Insurance
*CHILDRENS' EXPENSES*
Child Care		School supplies/expenses
a)		a)
b)		b)
School tuition		Lunch money
a)		a)
b)		b)
Allowance		Clothing/Diapers
Medical, dental, prescriptions		Grooming/Hygiene
Gifts		Entertainment
Activities		a)
a)		b)
*OTHER INSURANCE*
Health		Disability
Life		Other (specify)
a)		a)
b)		b)
*AFFIANT'S OTHER MISCELLANEOUS EXPENSES*
Dry cleaning and laundry		Clothing
Medical/Dental		Prescriptions
Affiant's gifts (holidays)		Entertainment
Vacations		Publications
Dues, clubs		Religious & Charities
Child support paid to former spouse		Alimony paid to former spouse
Miscellaneous
*TOTAL ABOVE EXPENSES*

*To Whom*	*Balance Due*	*Monthly Payment*













*TOTAL PAYMENTS TO CREDITORS*

Net monthly income from employment (deducting only state, federal, and FICA taxes)
Affiant's Pay Period (i.e. weekly, monthly)
Number of exemptions claimed

*C. TOTAL EXPENSES (from Section 5, "Average Monthly Expenses")*
HOUSEHOLD
AUTOMOBILE
CHILDRENS' EXPENSES
OTHER INSURANCE
AFFIANT'S OTHER MISCELLANEOUS EXPENSES
*TOTAL EXPENSES*