Rule text
IN THE COURT OF COMMON PLEAS ______________________________ DIVISION ______________________________ COUNTY, OHIO Case No. Plaintiff/Petitioner 1 Judge vs./and Magistrate Defendant/Petitioner 2 Instructions: Check local court rules to determine when this form must be filed. This affidavit is used to make complete disclosure of income, expenses, and money owed. It is used to determine child and spousal support. 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 you need more space, add additional pages. AFFIDAVIT OF BASIC INFORMATION, INCOME, AND EXPENSES Affidavit of _____________________________________ (Print Name) Date of marriage Date of separation SECTION I – BASIC INFORMATION Plaintiff/Petitioner 1 Defendant/Petitioner 2 Date of Birth _____________________________ Date of Birth ______________________________ Last 4 Digits of Social Security # XXX-XX-_____ Last 4 Digits of Social Security # XXX-XX-______ Phone Number___________________________ Phone Number___________________________ Email Address___________________________ Email Address____________________________ Is an interpreter needed? Yes or No Is an interpreter needed? Yes or No If yes, explain: ___________________________ If yes, explain: ___________________________ Health: Health: Good Fair Poor If health is not good, please explain: Good Fair Poor If health is not good, please explain:
Education: (Check highest level achieved) Grade School High School Associate Bachelor’s Post Graduate Education: (Check highest level achieved) Grade School High School Associate Bachelor’s Post Graduate Other Technical Certifications: Other Technical Certifications: Active Member of the U.S. Military Yes No Active Member of the U.S. Military Yes No SECTION II – INCOME Plaintiff/Petitioner 1 Defendant/Petitioner 2 Yes No Yes No Employed Date of Employment _______________________ _______________________ Name of Employer _______________________ _______________________ Payroll Address _______________________ _______________________ Payroll City, State, Zip _______________________ _______________________ Scheduled Paychecks Per Year 12 24 26 52 12 24 26 52 A. YEARLY INCOME, OVERTIME, COMMISSIONS, AND BONUSES FOR PAST THREE YEARS Plaintiff/Petitioner 1 Year Defendant/Petitioner 2 $__________________ 3 years ago 20 $ Base yearly income $__________________ 2 years ago 20 $ $__________________ Last year 20 $ $__________________ $__________________ 3 years ago 20 Yearly overtime, commissions, and/or bonuses $__________________ $__________________ 2 years ago 20 $__________________ $__________________ Last year 20 B. COMPUTATION OF CURRENT INCOME Plaintiff/Petitioner 1 Defendant/Petitioner 2 Base Yearly Income $ $ Average yearly overtime, commissions, and/or bonuses over last 3 years (from part A) $ $
Unemployment Compensation $ $ Disability Benefits Workers’ Compensation $_________________ $_________________ Social Security $_________________ $_________________ Other: $ $ Retirement Benefits Social Security $_________________ $_________________ Other: $ $ Spousal Support Received $ $ Interest and dividend income (source) $ $ Other income (type and source) __________________________ $ $ TOTAL YEARLY INCOME $ $ Supplemental Security Income (SSI) and/or public assistance $ $ Social Security or Veteran’s benefits received for child(ren) Based on parent’s disability Based on child’s disability $ $ Child support you receive from a child support enforcement agency or court order for minor and/or dependent child(ren) not of the marriage or relationship $ $ SECTION III – CHILDREN AND HOUSEHOLD RESIDENTS Minor and/or dependent child(ren) who is/are adopted or born from this marriage or relationship: Name Date of birth Living with
In addition to the above child(ren): Plaintiff/Petitioner 1 has other minor biological or adopted child(ren). Defendant/Petitioner 2 has other minor biological or adopted child(ren). There is/are adult(s) in your household. SECTION IV – EXPENSES List monthly expenses below for your present household. A. MONTHLY HOUSING EXPENSES Rent or first mortgage (including taxes and insurance) $ Second mortgage/equity line of credit $ Real estate taxes (if not included above) $ Renter or homeowner's insurance (if not included above) $ Homeowner or condominium association fee $ Utilities ° Electric $ ° Gas, fuel oil, propane $ ° Water and sewer $ ° Telephone and/or cell phone $ ° Trash collection $ ° Cable/satellite television $ ° Internet service $ Cleaning $ Lawn service and/or snow removal $ Other: ______________________________________________________ $ ______________________________________________________ $ TOTAL MONTHLY: $ B. OTHER MONTHLY LIVING EXPENSES Food ° Groceries (including food, paper, cleaning products, toiletries, and other) $ ° Restaurant $ Transportation ° Vehicle loan, lease $ ° Vehicle maintenance $
° Parking, public transportation $ Clothing ° Clothes (other than child(ren)’s) $ ° Dry cleaning and laundry $ Personal grooming ° Hair and nail care $ ° Other: ____________________________________________________ $ Other: _______________________________________________________ $ TOTAL MONTHLY: $ C. MONTHLY MINOR CHILD-RELATED EXPENSES (for child(ren) of the marriage or relationship) Work and/or education-related child care $ Other child care $ Extraordinary parenting time travel cost $ School tuition $ School lunches $ School supplies $ Extracurricular activities and lessons $ Clothing $ Child(ren)’s allowances $ Special and extraordinary needs of child(ren) (not included elsewhere) $ Other: $ TOTAL MONTHLY: $ D. MONTHLY INSURANCE PREMIUMS Life $ Auto $ Health $ Disability $ Other: $ TOTAL MONTHLY: $
E. MONTHLY WORK AND EDUCATION EXPENSES FOR SELF Mandatory work expenses (union dues, uniforms, or other) $ Additional income taxes paid (not deducted from wages) $ Tuition $ Books, fees, and other $ College loan $ Other: ______________________________________________________ $ ______________________________________________________ $ TOTAL MONTHLY: $ F. MONTHLY HEALTH CARE EXPENSES (not covered by insurance) Physicians $ Dentists and orthodontists $ Optometrists and opticians $ Prescriptions $ Other: $ TOTAL MONTHLY: $ G. MISCELLANEOUS MONTHLY EXPENSES Extraordinary obligations for other minor/handicapped child(ren) [for child(ren) who were not born of this marriage or relationship and were not adopted by these parties] $ Child support for child(ren) who were not born of this marriage or relationship and were not adopted by these parties $ Expenses paid for adult child(ren) or other dependent(s) $ Spousal support paid to former spouse(s) $ Subscriptions and books $ Charitable contributions $ Memberships (associations and clubs) $ Travel and vacations $ Pets $ Gifts $ Attorney fees $
Other: _______________________________________________________ $ _______________________________________________________ $ TOTAL MONTHLY: $ H. MONTHLY INSTALLMENT PAYMENTS INCLUDING BANKRUPTCY PAYMENTS (Do not repeat expenses already listed.) Examples: car, credit card, rent-to-own, or cash advance payments To whom paid Purpose Balance due Monthly payment $ $ $ $ $ $ $ $ $ $ $ $ TOTAL MONTHLY: $ GRAND TOTAL MONTHLY EXPENSES (Sum of A through H): $
OATH OR AFFIRMATION (Do not sign until Notary Public is present) I, (print name), swear or affirm that I have read this Affidavit and, to the best of my knowledge and belief, the facts and information stated in this Affidavit are true, accurate, and complete. I understand that if I do not tell the truth, I may be subject to penalties for perjury. Your Signature STATE OF _____________________)) SS COUNTY OF ___________________) Sworn to or affirmed before me by this day of,. ______________________________________ Signature of Notary Public ______________________________________ Printed Name of Notary Public Commission Expiration Date: _____________ (Affix seal here)