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 EARL R. McGIMPSEY

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