Fillable IN THE COURT OF COMMON PLEAS, WOOD COUNTY, (Fairfield County)

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IN THE COURT OF COMMON PLEAS, WOOD COUNTY, (Fairfield County)

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IN THE COURT OF COMMON PLEAS, WOOD COUNTY, OHIO
DOMESTIC RELATIONS
__________________________
DOB:_____________
Plaintiff/Petitioner 1
vs./and
__________________________
DOB:______________
Defendant/Petitioner 2
CASE NO. _________________________
JUDGE ___________________________
MAGISTRATE _____________________
SCHEDULE A
(Original Actions)
AFFIDAVIT OF INCOME AND
EXPENSES
STATE OF OHIO, COUNTY OF WOOD, SS:
Now comes _________________________________, affiant, and having been duly sworn,
states:
Date of Marriage:
Place of Marriage:
Date of Separation:
Maiden Name:
Is Party Pregnant?
Restore to Former Name?
MINOR AND/OR DEPENDENT CHILDREN OF THIS MARRIAGE: (Include the parties’ adopted
children and those over 18 and handicapped)
Name:
DOB:
Name:
DOB:
Name:
DOB:
Name:
DOB:
Name:
DOB:
Unemancipated child(ren) from prior relationship? _________ How many? _________
_________________Your Name
________________Spouse’s Name
Home Phone No.
Email Address
Job Title
Name of Employer
Payroll Address
Name of Attorney
Attorney Phone No.
12/24/26/52
Paychecks Per Year
12/24/26/52
$
Year-to-date Income
$
$
Prior Year Gross Income
$
$
Annual Income
$
MONTHLY INCOME
________________Your Name
______________Spouse’s Name
Average Salary or
Hourly Wages
Overtime (Average)
Bonuses (received
annually divided by 12)
Pension/Retirement
Social Security/S.S.I.
Unemployment/Worker’s
Compensation
Veteran’s
benefits/Armed Forces
Allotment
Spousal Support
Received
Rental Income
Interest/Trust Income
Dividends
Self-Employed (Adj.
Gross Income)
Other Income
SUBTOTAL
State Source
ADC/General Relief
Food Stamps
Disability
Child Support Received
TOTAL OF ALL
INCOME
MONTHLY DEDUCTIONS FROM PAYCHECK
______________Your Name
___________Spouse’s Name
Court Ordered Child Support
Federal Income Tax
State Income Tax
City Income Tax
School Tax
Social Security/Public Retirement
Union Dues
Charity
Pension/Retirement Account
Savings
Bonds/Stock Purchase
Medical Insurance
Life/Disability Insurance
Other: (Medicare)
TOTAL MONTHLY
DEDUCTIONS:
OTHER ALLOWABLE DEDUCTIONS
Child Care Expenses for WORK ONLY:
Court Ordered Spousal Support:
Current spouse:
Prior Spouse:
Insurance Available for child(ren) through employer? ________YES _______NO
Your cost for insurance: ________/month ________/month
CURRENTLY MONTHLY EXPENSES
YOURSELF
CHILDREN
FOOD:
Groceries
Restaurant
School Lunch
HOUSING:
First Mortgage/Rent
Second Mortgage/Home Equity
Taxes
Insurance
Maintenance
Lawn Care
UTILITIES:
Electric
Gas
Fuel Oil
Sewer/Water
Telephone
Garbage
Cable/Internet
MEDICAL: Out-of-pocket
Doctor
Dentist
Drugs
Counseling
Optical
Orthodontist
TRANSPORTATION:
Car Loan/Lease
Car Insurance
Gasoline
Maintenance
Parking
School Bus
CLOTHING:
Regular
Special
INSURANCE:
Life
Health
Disability
Personal Property
ENRICHMENT:
Entertain
Lessons
Sports
Clubs
Hobbies
Vacation
Magazines
EDUCATION:
Tuition
Books
Fees
Tutor
Activities
MISCELLANEOUS/PERSONAL:
Gifts
Cable
Newspaper
Barber/Beautician
Toiletries
Veterinarian
Laundry
SUBTOTAL
ADDITIONAL LONG TERM EXPENSES
Installment/Credit Card Debt
MONTHLY
BALANCE
Student Loan
Promissory Note
SUBTOTAL LONG TERM
MONTHLY EXPENSES
TOTAL ALL MONTHLY EXPENSES
Affiant states that the information contained herein is complete and accurate to the best of his/her information,
knowledge or belief under penalty of law. Further, Affiant certifies that (s)he has caused a copy hereof to be
mailed or delivered to the other party at the time of filing same with the Court.
_____________________________________
Your Signature
Sworn to before me and subscribed in my presence, this _________ day of ____________, 20___.
________________________________
Notary Public
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IN THE COURT OF COMMON PLEAS, WOOD COUNTY, (Fairfield County)

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Completed 24 November 2021

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