IN THE COMMON PLEAS COURT OF _____________

Court Form 2

Eff. 7/1/01

IN THE COMMON PLEAS COURT OF HURON COUNTY, OHIO

DIVISION OF DOMESTIC RELATIONS

______________________________________ : Case No._________________________________

Plaintiff/Petitioner(1)

DOB _________________________________ : CSEA No. _______________________________

Address _______________________________ : Family File No. ___________________________

________________________________ : JUDGE JAMES CONWAY

V. :

______________________________________ MAGISTRATE BRADLEY E. SALES

Defendant/Petitioner (2)/Respondent :

DOB _________________________________ Affidavit of Income, Expenses and Property of ___________________

Address _______________________________ (Name)

___________________________

		Date of Marriage
		Date of Separation

Notes: This affidavit must be filed and served in accordance with Local Rules of Court. Pages 1 through 8 and page 13 must be completed and filed and served with every post-decree motion that concerns a modification of support. You will be required to provide proof of income per local rule and O.R.C. 3119.021. You are under a continuing legal duty to file an updated version of this form if you learn of any additional information. If more space is needed, attach additional page(s).

I. Income [As defined in O.R.C. 3119.01]:

A. Gross Yearly Income from Employment (If not known, please estimate. Put “EST” after each estimated figure.)

	Husband/Father		Wife/Mother
Gross Yearly Employment Income
Employer
Payroll Address
City, State, Zip
Check the number of Paychecks per year	¨12 ¨24 ¨26 ¨52		¨12 ¨24 ¨26 ¨52
Year-to-date Gross Income		Through date of		Through date of
Prior Year’s Tax Refund

B. Annual Overtime, Commissions, Bonuses

(If not known, please estimate. Put “EST” after each estimated figure.)

Husband/Father			Wife/Mother
Year 3 is Most Recent Year	Base Income	Overtime, Commission, Bonuses	Year 3 is Most Recent Year	Base Income	Overtime, Commission, Bonuses
19__ Year 1			19__ Year 1
19__ Year 2			19__ Year 2
20__ Year 3			20__ Year 3
Year-to-Date This Year Through ____			Year-to-Date This Year Through ____

C. Gross Self-Employment Income

(If not known, please estimate. Put “EST” after each estimated figure.)

Use Gross Annual Figures for Most Recent Full Year. See O.R.C. 3119.021	Husband/Father	Wife/Mother
Business Receipts
Ordinary & Necessary Business Expenses
Net Business Income

D. Other Income

All other income, actual or expected, including pension, social security, workers compensation, commissions, royalties, disability benefits, trust income, annuities, reoccurring capital gains, unemployment benefits, rents, expense-sharing, dividends, interest, AFDC, SSI, food stamps, spousal support received from a prior spouse, etc. (If not known, please estimate. Put “EST” after each estimated figure.)

Husband/Father		Wife/Mother
Per Year	Describe	Per Year	Describe

E. Total Annual Income

Husband/Father		Wife/Mother
Total gross annual income		Total gross annual income
Total average gross monthly income	+ 12 =	Total average gross monthly income	+ 12 =
Average monthly deductions	Less	Average monthly deductions	Less
Total net monthly income	=	Total net monthly income	=

F. Benefits of Employment

(Use of company car, country club memberships, stock options, etc.)

Husband/Father		Wife/Mother
Benefits	Values	Benefits	Values

II. Information Required for Support Calculation:

A. Minor or Dependent Children of this Marriage

(Include adopted children and any child of the parties who is over 18 and handicapped.)

Child’s Name	Date of Birth	Residing With

B. Other Minor Children Living in My Household

Child’s Name	Date of Birth	Relationship

C. Other Minor Children of Mine, Not Living in My Household

Child’s Name	Date of Birth	Relationship

III. Child Support Guidelines Adjustment:

	Husband/Father (All Figures Per Year)	Wife/Mother (All Figures Per Year)
Court Ordered Child Support You Pay for Other Child(ren) in Another Case
Court Ordered Spousal Support You Pay to a Former Spouse
Number of Your Other Dependent Children Living With You From a Previous Marriage or Relationship
Court Ordered Child Support You Receive for the Dependent Child(ren) You Indicated on Line Above
Child Care Expenses You Pay for Child(ren) of this Marriage (Employment or Educational-Related)
Local Income Taxes Paid or Rate of Tax where you Life or Work	or: %	or: %
Self-Employment Tax (5.6% of A.G.I.)
Health Insurance Premium for Children (Family Plan Cost Less Individual Plan Cost)
For Post Decree Modifications Only:
Current Spouse’s Gross Income
Number of Your Other Dependent Children Living With You From Your Present Marriage or Relationship [Excluding unadopted step children]

IV. Affiant’s Monthly Living Expenses:

List your ACTUAL expenses for your present household in the first column. Give estimated expenses if you don’t have exact figures. If you expect changes soon, list your ANTICIPATED expenses in your household after the divorce case in the second column. Explain why you expect your expenses to change. Also, if you are living with your parents or someone is helping you with your living expenses, please explain.

My Average Monthly Expenses

Actual Monthly Expenses

in My Present Household

Anticipated Future Monthly

Expenses in My Household

There are now ______Adults and

_______ Children living in my present household.

I am assisted with my living expenses by:

The reason I expect my household living expenses to change soon is:

A. Housing	Actual	Anticipated
Rent or First Mortgage
Real Estate Taxes (if not included above)
Real Estate Insurance (if not included above)
Second Mortgage, if any
UTILITIES: Electric (level billing or average/month)
Gas (if billed separately)
Fuel Oil/Propane
Water & Sewer
Telephone (basic monthly charge)
Water Softener
Trash Collection
Telephone (average long distance)
Cable Television
Home Cleaning, Maintenance, Repair
Lawn Service, Snow Removal
Other: _________________________________
Housing Total	(A)	(A)

B. Other Necessary Living Expenses	Actual	Anticipated
FOOD, ETC.: Grocery (include food, paper & cleaning products, toiletries, etc.)
Restaurant
TRANSPORTATION, ETC.: Car Loan or Lease
Gasoline
Car Maintenance & Repair
Parking, Public Transit

B. Other Necessary Living Expenses (Con’t.)	Actual	Anticipated
CLOTHING, ETC.: Clothes
Dry Cleaning, Laundry
Personal Grooming
Other: _______________________________
Other: _______________________________
Other Necessities Total	(B)	(B)

C. Child-Related Expenses	Actual	Anticipated
Child Care, Work or Educational Related
Clothing
School Lunches
Children’s Allowances
Extra-Curricular Activities
Other: ______________________________
Child-Related Expenses Total	(C)	(C)

	Actual		Anticipated
D. Educational Expenses for:	You	Child(ren)	You	Child(ren)
Tuition
Books
Fees
Tutor
Activities
College Loan Repayment
Other: ______________________________
Education Total	(D)			(D)

	Actual		Anticipated
E. Medical Expenses (Out-of-pocket) for:	You	Child(ren)	You	Child(ren)
Doctor
Dentist
Optical
Orthodontist
Prescriptions
Other: _______________________________
Medical Total	(E)			(E)

F. Insurance	Actual	Anticipated
Life
Auto
Health
Disability
COBRA Insurance Coverage
Personal Property
Other: _______________________________
Insurance Total	(F)	(F)

G. Enrichment (Your expenses. Put child(ren)’s expenses under C or D, above)	Actual	Anticipated
Entertainment
Lessons
Books, Newspapers, Magazines

G. Enrichment (Con’t.)	Actual	Anticipated
Sports
Clubs
Hobbies
Donations
Gifts
Vacation
Other: _______________________________
Enrichment Total	(G)	(G)

H. Miscellaneous Expenses (Include expenses and debts not previously listed.)	Actual	Anticipated
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Miscellaneous Expenses Total	(H)	(H)

Actual Anticipated

Grand Total of Monthly Expenses

(Sum of A - H in each column)

AFFIDAVIT OF PROPERTY

List ALL YOUR PROPERTY AND DEBTS, those of your spouse, and joint property and debts. Do not leave any category blank. For each item, if non, put NONE.” If you don’t know exact figures for any item, give your best estimate, and put “EST”. If more space is needed, attached extra pages.

I. Real Estate Interests:

Address

Titled to Husband, Wife or Both

Present Fair Market Value

Mortgages: Balance Due

Monthly Mortgage Payments

II. Other Assets

Category	Description (Also list who has possession)	Titled to Husband, Wife, or Both	Present Fair Market Value (Also list balance due on any liens)
A. Vehicles, Other Licensed Property	(Include automobiles, trucks, motorcycles, boats, motors, motor homes, etc.)
1.
2.
3.
B. Financial Accounts	(Include checking, savings, CD’s, POD accounts, money market accounts, etc.)
1.
2.
3.
C. Pensions & Retirement Plans	(Include profit-sharing, IRA’s 401K plans, etc.) Describe each type of plan.
1.
2.
3.
D. Publicly Held Stocks, Bonds, Securities, & Mutual Funds
1.
2.
3.

Category	Description (Also list who has possession)	Titled to Husband, Wife, or Both	Present Fair Market Value (Also list balance due on any liens)
E. Closely Held Stocks and Other Business Interests	(Describe type of business and type of ownership.)
1.
2.
F. Life Insurance	(Include insurance provided by employer, term, whole life, any cash value or loans.)
1.
2.
G. Furniture & Appliances	(Estimate value of those in your possession and value of those in your spouse’s possession)
1. In your possession
2. In spouse’s possession
H. Safe Deposit Box	(Give location and describe contents)

I. All Other Assets	(Include collections, rare books, stamps, guns, antiques, art objects, computers, machinery, personal injury/workers compensation claims, promissory notes, loans to others, tax refunds due, interests in estates or trusts, franchises, copyrights, etc.)
1.
2.
J. Transfer of Assets	Explanation: List the name and address of any person [other than creditors listed on your Affidavit] who has received money or property from you exceeding $100 in value in the past 12 months and the reason for each transfer.
1.
2.
K. Lost Assets	Explanation: List any item you claim is lost or missing as of this date, and its value.
1.
2.

III. Debts:

List ALL YOUR DEBTS, debts of your spouse, and joint depts. Do not leave any category blank. For each item, if none, put “NONE”. If you don’t know exact figures for any item, give your best estimate, and put “EST.” If more space is needed, attached extra pages.

Type	Name of Creditor/ Purpose of Debt	Total Debt Due	Monthly Payment
A. Secured debts (Mortgages, car, etc.)
1.
2.
3.
4.
B. Unsecured debts, including credit cards
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

IV. Bankruptcy:

Filed by: Wife, Husband, Both

Date of Filing:

Case Number

Date of Discharge or Relief from Stay

Type of Case

(Ch. 7, 11, 12, 13)

Currently Monthly Payments

V. Separate Property Claims: [As defined in O.R.C. 3105.171(A)(6)(a)]

If you are making any claims in any of the categories below, explain the nature and amount of your claim.

Category	Description	Particulars leading to your claim of separate ownership	Present Fair Market Value	Present Debt
A. Inheritances


B. Property Owned Before Marriage


C. Passive Income and Appreciation from Separate Property


D. Property Acquired After a Decree of Legal Separation

Category	Description	Particulars leading to your claim of separate ownership	Present Fair Market Value	Present Debt
E. Prenuptial Agreement


F. Personal Injury Compensation (Except Loss of Marital Earnings)


G. Gifts made solely to One Spouse

OATH OF AFFIANT

I, ___________________________________ (print) hereby swear or affirm that the information set forth in this Affidavit of Income, Expenses and Property above is true, complete, and accurate. I understand that falsification of this document many result in a contempt of court finding against me which could result in a jail sentence and fine, and that falsification of this document may also subject me to criminal penalties for perjury (O.R.C. 2921.22).

_____________________________________________

AFFIANT

Sworn to and subscribed before me this _________ day of __________________________ , _________

_____________________________________________

Notary Public

Court Form 2 Supplement

Eff. 7/1/01

IN THE COMMON PLEAS COURT OF HURON COUNTY, OHIO

DIVISION OF DOMESTIC RELATIONS

_________________________________ : Case No. _______________________

Plaintiff/Petitioner(1)

: CSEA No. _______________________

V. : Family File No. ______________________

_________________________________ : JUDGE EARL R. McGIMPSEY

Defendant/Petitioner(2)/Respondent

: MAGISTRATE BRADLEY E. SALES

HEALTH INSURANCE DISCLOSURE AFFIDAVIT (HIDA)

Instructions: This affidavit must be filed according to local rules of court. You are required to disclose all requested information. You may need to consult your employer to complete this form. There is a continuing legal duty to update the information contained in this form. If more space is needed, attached additional page(s). Please type or print legibly.

Children Subject to Support Order

Husband/Father/Other		Name
DOB	SS#	DOB	SS#
Street Residence Address		Name
		DOB	SS#

Wife/Mother/Other		Name
DOB	SS#	DOB	SS#
Street Residence Address		Name
		DOB	SS#

You are to disclose all requested information in the column for you and in the column for the other party.

Part I Part II

Husband/Father/Other Wife/Mother/Other

Name		Name
Employer		Employer
Employer Address		Employer Address

Employer Phone		Employer Phone

Is Medicaid coverage available? ¨Yes ¨No		Is Medicaid coverage available? ¨Yes ¨No
Is Medicare coverage available? ¨Yes ¨No		Is Medicare coverage available? ¨Yes ¨No
Is family health insurance available either through the employer or another group or organization? ¨Yes ¨No		Is family health insurance available either through the employer or another group or organization? ¨Yes ¨No
If not, is private insurance available? ¨Yes ¨No		If not, is private insurance available? ¨Yes ¨No
Is coverage presently in effect? ¨Yes ¨No		Is coverage presently in effect? ¨Yes ¨No
Who is presently covered? ¨Yes ¨No		Who is presently covered? ¨Yes ¨No
Name	Relationship	Name	Relationship

Insurer/Plan Name	Phone	Insurer/Plan Name	Phone
Address		Address

Policy/Group #		Policy/Group #
Other Policy? Group# (if another policy is available)		Other Policy? Group# (if another policy is available)

You are to disclose all requested information in the column for you and in the column for the other party.

Part I Part II

Husband/Father/Other Wife/Mother/Other

Is there a cost for coverage? ¨Yes ¨No			Is there a cost for coverage? ¨Yes ¨No

Special Instruction - The court requires both the family cost and the individual cost information.			Special Instruction - The court requires both the family cost and the individual cost information.
What is the annual cost for family coverage?			What is the annual cost for family coverage?
$			$
What is the annual cost for individual coverage?			What is the annual cost for individual coverage?
$			$

You are to disclose all requested information in the column for you and in the column for the other party.

Part I Part II

Husband/Father/Other Wife/Mother/Other

Is a prescription card available? ¨Yes ¨No			Is a prescription card available? ¨Yes ¨No
Is a co-payment required? ¨Yes ¨No			Is a co-payment required? ¨Yes ¨No
If yes, what is the co-payment?			If yes, what is the co-payment?
$	Per Prescription		$	Per Prescription
Is dental coverage available? ¨Yes ¨No			Is dental coverage available? ¨Yes ¨No
Insurer/Plan Name		Phone	Insurer/Plan Name		Phone
Address			Address


Policy/Group #			Policy/Group #
Is there a cost for dental coverage? ¨Yes ¨No			Is there a cost for dental coverage? ¨Yes ¨No
Special Instruction - The court requires both the family cost and the individual cost information.			Special Instruction - The court requires both the family cost and the individual cost information.
What is the annual cost for family dental coverage?			What is the annual cost for family dental coverage?
$			$
What is the annual cost for individual dental coverage?			What is the annual cost for individual dental coverage?
$			$
Is a dental insurance card available? ¨Yes ¨No			Is a dental insurance card available? ¨Yes ¨No
Are dental insurance cards required for service? ¨Yes ¨No			Are dental insurance cards required for service? ¨Yes ¨No
Is vision coverage available? ¨Yes ¨No			Is vision coverage available? ¨Yes ¨No
Insurer/Plan Name		Phone	Insurer/Plan Name		Phone
Address			Address


Policy/Group #			Policy/Group #

You are to disclose all requested information in the column for you and in the column for the other party.

Part I Part II

Husband/Father/Other Wife/Mother/Other

Is there a cost for vision coverage? ¨Yes ¨No			Is there a cost for vision coverage? ¨Yes ¨No
Special Instruction - The court requires both the family cost and the individual cost information.			Special Instruction - The court requires both the family cost and the individual cost information.
What is the annual cost for family vision coverage?			What is the annual cost for family vision coverage?
$			$
What is the annual cost for individual vision coverage?			What is the annual cost for individual vision coverage?
$			$

Is a vision insurance card available? ¨Yes ¨No		Is a vision insurance card available?¨Yes ¨No
Are vision insurance cards required for services? ¨Yes ¨No		Are vision insurance cards required for services? ¨Yes ¨No
Is COBRA insurance available? ¨Yes ¨No (A continuation of present insurance coverage after termination of employment or marriage)		Is COBRA insurance available? ¨Yes ¨No (A continuation of present insurance coverage after termination of employment or marriage)
If yes, at what cost? Check One:		If yes, at what cost? Check One:
$	Per ¨Mo. ¨Yr.	$	Per ¨Mo. ¨Yr.

Instructions: In a divorce or post decree action, only the party filling out the Health Insurance Disclosure Affidavit (HIDA) is required to sign the oath. In a dissolution action, both parties must sign the oath.

OATH OF AFFIANT(S) - SIGNATURE(S) MUST BE NOTARIZED

I hereby swear or affirm that the information set forth in this health insurance disclosure affidavit above is true, complete and accurate. I understand that falsification of this document may result in a contempt of court finding against me which could result in a jail sentence and fine, and that falsification of this document may also subject me to criminal penalties for perjury (O.R.C. 2921.11).

AFFIANT - Husband/Father/Other AFFIANT - Wife/Mother/Other

Sworn to and subscribed before me this __________ day of _____________________________, 20 _____.

_________________________________________

Notary Public

Is a health insurance card available? ¨Yes ¨No		Is a health insurance card available? ¨Yes ¨No
Are insurance cards required for service? ¨Yes ¨No		Are insurance cards required for service? ¨Yes ¨No
Does the plan cover hospitalization? ¨Yes ¨No		Does the plan cover hospitalization? ¨Yes ¨No
Is there a deductible for services? ¨Yes ¨No		Is there a deductible for services? ¨Yes ¨No
If yes, what is the deductible?		If yes, what is the deductible?
$	Check one: Per ¨Visit ¨Mo. ¨Yr.	$	Check one: Per ¨Visit ¨Mo. ¨Yr.
Is there a co-payment required? ¨Yes ¨No		Is there a co-payment required? ¨Yes ¨No
If yes, what is the co-payment?		If yes, what is the co-payment?
$	Check one: Per ¨Visit ¨Mo. ¨Yr.	$	Check one: Per ¨Visit ¨Mo. ¨Yr.
Does the plan cover doctor visits? ¨Yes ¨No		Does the plan cover doctor visits? ¨Yes ¨No
Is there a deductible for services? ¨Yes ¨No		Is there a deductible for services? ¨Yes ¨No
If yes, what is the deductible?		If yes, what is the deductible?
$	Check one: Per ¨Visit ¨Mo. ¨Yr.	$	Check one: Per ¨Visit ¨Mo. ¨Yr.
Is there a co-payment required? ¨Yes ¨No		Is there a co-payment required? ¨Yes ¨No
If yes, what is the co-payment?		If yes, what is the co-payment?
$	Check one: Per ¨Visit ¨Mo. ¨Yr.	$	Check one: Per ¨Visit ¨Mo. ¨Yr.