Fillable Domestic Relations Affidavit

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Domestic Relations Affidavit

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1
Domestic Relations Affidavit
IN THE JUDICIAL DISTRICT
COUNTY, KANSAS
IN THE MATTER OF )
)
)
Party Name )
)
and ) Case No.
)
)
)
Party Name )
DOMESTIC RELATIONS AFFIDAVIT OF
(name)
1. Party Name Residence
Party Name XXX-XX-_ _ _ _
Birth Month/YearSocial Security Number Telephone
2. Party Name Residence
Party Name XXX-XX-_ _ _ _
Birth Month/YearSocial Security Number Telephone
3. Date of Marriage:
4. Number of Marriages:
Party Name Party Name
5. Number of children of the relationship:
6. Names, Social Security Numbers, the month and year of each child’s birth and ages of minor children of
the relationship:
Name Social Security Number Birth Age Custodian
XXX-XX-_ _ _ _ Month /Year
2
7. Names, Social Security Numbers, and ages of minor children of previous relationships and facts as to
custody and support payments paid or received, if any.
Social Support Paid
Name Security No. Age Custodian Payment or Rec’d
XXX-XX-_ _ _ _
$
$
$
$
8. Party Name is employed by (name)
(address)
Party Name is employed by (name)
(address)
with monthly income as follows:
A. Wage Earner Party Name Party Name
1. Gross Income $ $
2. Other Income $ $
3. Subtotal Gross Income $ $
4. Federal Withholding $ $
(Claiming _____ exemptions)
5. Federal Income Tax $ $
6. OASDHI $ $
7. Kansas Withholding $ $
8. Subtotal Deductions $ $
9. Net Income $ $
B. Self-Employed Party Name Party Name
1. Gross Income from
self-employment $ $
2. Other Income $ $
3. Subtotal Gross Income $ $
4. Reasonable Business Expenses (-) $ $
(Itemize on attached exhibit)
5. Self-Employment Tax (-) $ $
6. Business Net Income $ $
7. Estimated Tax Payments $ $
(Claim _____ exemptions)
8. Federal Income Tax $ $
9. Kansas Withholding $ $
10. Subtotal Deductions $ $
3
11. Net Income $ $
(Line B.3. minus Line B.9.)
Pay period:
Party Name Party Name
9. The liquid assets of the parties are:
Joint or Individual
Item Amount (Specify)
A. Checking Accounts (Do not list account numbers):
$
$
B. Savings Accounts (Do not list account numbers):
$
$
C. Cash
Party Name $
Party Name $
D. Other
$
$
10. The monthly expenses of each party are: (Please indicate with an asterisk all figures which are estimates
rather than actual figures taken from records.)
A. Party Name Party Name
Item (Actual or Estimated) (Actual or Estimated)
1. Rent $ $
2. Food $ $
3. Utilities/services:
Trash Service $ $
Newspaper $ $
Telephone $ $
Cell Phone $ $
Cable $ $
Gas $ $
Water $ $
Lights $ $
Other $ $
4. Insurance:
Life $ $
Health $ $
Car $ $
House/Rental $ $
Other $ $
5. Medical and dental $ $
6. Prescriptions drugs $ $
7. Child care (work-related) $ $
4
8. Child care (non-work-related) $ $
9. Clothing $ $
10. School expenses $ $
11. Hair cuts and beauty $ $
12. Car repair $ $
13. Gas and oil $ $
14. Personal property
tax
$
$
Party Name Party Name
Item (Actual or Estimated) (Actual or Estimated)
15. Miscellaneous (Specify)
$ $
$ $
16. Debt Payments (Specify)
$ $
$ $
Total $ $
*Show house payments, mortgage payments, etc., in Section 10.B.
B. Monthly payments to banks, loan companies or on credit accounts: (Indicate actual or estimated
monetary amount in each column; use asterisk for secured.) DO NOT LIST ANY PAYMENTS
INCLUDED IN PART 10.A ABOVE.
When Amount of Date of Responsibility
Creditor Incurred Payment Last Payment Balance
Party Name Party Name
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
Subtotal of Payments $ $
Total $ $
C. Total Living Expenses
Party Name Party Name
(Actual or Estimated) (Actual or Estimated)
1. Total funds available to $ $
Both Parties
(from No. 8)
2. Total needed $ $
(from No. 10.A and B)
3. Net Balance $ $
4. Projected child support $ $
5
D. Payments or contributions received, or paid, for support of others. Specify source and amount.
Source Party Name Party Name
(+/-) $ $
(+/-) $ $
11. How much does the party who provides health care pay for family coverage?
$ per .
How much does it cost the provider to furnish health insurance only on the provider?
$ per .
FURNISH THE FOLLOWING INFORMATION IF APPLICABLE.
12. Income and financial resources of children.
Income/Resources Amount
$
$
13. Child support adjustments requested.
□ parenting time adjustment □ agreement past majority
□ income tax consideration □ long distance parenting time
□ special needs □ overall financial conditions
□ other: ________________________________________________
14. All other personal property including retirement benefits (including but not limited to qualified plans such
as profit-sharing, pension, IRA, 401(k), or other savings-type employee benefits, nonqualified plans, and
deferred income plans), and ownership thereof (joint or individual), including policies of insurance,
identified as to nature or description, ownership (joint or individual), and actual or estimated value.
Joint or Individual
Amount (Specify)
$
$
$
$
THE FOLLOWING NEED NOT BE FURNISHED IN POST JUDGMENT PROCEDURES.
15. List real property identified as to description, ownership (joint or individual) and actual or estimated value.
Property Description Ownership Actual/Estimated Value
6
16. Identify the property, if any, acquired by each of the parties prior to marriage or acquired during marriage
by a will or inheritance.
Source of Actual/
Property Description Ownership Ownership Estimated Value
17. List debt obligations, including maintenance, not listed in Section 10.A or 10.B above, identified as to
name or names of payor or payors and payees, balance due and rate at which payable; and, if secured,
identify the encumbered property.
Debt Balance Payment Encumbered
Obligation Payor Payee Due Rate Property
8. List health insurance coverage and the right, pursuant to ERISA §§ 601-608, 29 U.S.C.
§§ 1161-1168 (1986), to continued coverage by the spouse who is not a member of the
covered employee group.
Health Insurance COBRA Continuation
Yes No Unknown
I declare under penalty of perjury under the laws of the State of Kansas that the foregoing is true, correct
and complete.
Executed on the _______ day of _________________________, 20____.
Name (Print):
Signature
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Domestic Relations Affidavit

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Completed 19 March 2021

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