Guernsey County Common Pleas Court Local Rules

AFFIDAVIT OF INCOME AND EXPENSES

COURT OF COMMON PLEAS

COUNTY, OHIO
Case No.

Plaintiff/Petitioner 1
Judge

v./and

Defendant/Petitioner 2
Magistrate

SECTION I - INCOME

Affidavit of

Date of marriage Date of separation

Your Name      Spouse’s Name

Employed
Yes No Yes No

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

Your Name      Spouse’s Name

Base yearly income

Yearly overtime, commissions and/or bonuses

B. COMPUTATION OF CURRENT INCOME

Your Name      Spouse’s Name

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) or public assistance

SECTION II – CHILDREN AND HOUSEHOLD RESIDENTS

Minor and/or dependent child(ren) who are from this marriage or relationship:

Name
Date of birth
Living with

In addition to the above children there is/are in your household:

_____ adult(s)

_____ other minor and/or dependent child(ren).

SECTION III – EXPENSES

List monthly expenses below for your present household.

A. MONTHLY HOUSING EXPENSES

Rent or first mortgage (including taxes and insurance)

Real estate taxes (if not included above)

Real estate/homeowner’s insurance (if not included above)

Second mortgage/equity line of credit

Utilities

Electric

Gas, fuel oil, propane

Water and sewer

Telephone

Trash collection

Cable/satellite television

Cleaning, maintenance, repair

Lawn service, snow removal

Other:

TOTAL MONTHLY:

B. OTHER MONTHLY LIVING EXPENSES

Food

Groceries (including food, paper, cleaning products, toiletries, other)

Restaurant

Transportation

Vehicle loans, leases

Vehicle maintenance (oil, repair, license)

Gasoline

Parking, public transportation

Clothing

Clothes (other than children’s)

Dry cleaning, laundry

Personal grooming

Hair, nail care

Other

Cell phone

Internet (if not included elsewhere)

Other

TOTAL MONTHLY

C. MONTHLY CHILD-RELATED EXPENSES

(for children of the marriage or relationship)

Work/education-related child care

Other child care

Unusual parenting time travel

Special and unusual needs of child(ren) (not included elsewhere)

Clothing

School supplies

Child(ren)’s allowances

Extracurricular activities, lessons

School lunches

Other

TOTAL MONTHLY

D. INSURANCE PREMIUMS

Life

Auto

Health

Disability

Renters/personal property (if not included in part A above)

Other

TOTAL MONTHLY

E. MONTHLY EDUCATION EXPENSES

Tuition

Self

Child(ren)

Books, fees, other

College loan repayment

Other

TOTAL MONTHLY:

F. MONTHLY HEALTH CARE EXPENSES

(not covered by insurance)

Physicians

Dentists

Optometrists/opticians

Prescriptions

Other

TOTAL MONTHLY:

G. MISCELLANEOUS MONTHLY EXPENSES

Extraordinary obligations for other minor/handicapped child(ren) (not stepchildren)

Child support for children who were not born of this marriage or relationship and were not adopted of this marriage

Spousal support paid to former spouse(s)

Subscriptions, books

Entertainment

Charitable contributions

Memberships (associations, clubs)

Travel, vacations

Pets

Gifts

Bankruptcy payments

Attorney fees

Required deductions from wages (excluding taxes, Social Security and Medicare) (type)

Additional taxes paid (not deducted from wages) (type)

Other

TOTAL MONTHLY:

H. MONTHLY INSTALLMENT PAYMENTS

(Do not repeat expenses already listed.)

Examples: car, credit card, rent-to-own, cash advance payments

To whom paid Purpose Balance due Monthly payment

TOTAL MONTHLY:

GRAND TOTAL MONTHLY EXPENSES (Sum of A through H):

OATH

(Do not sign until notary is present.)

I, , swear or affirm that I have read this document 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.