Fill - Free fillable IN THE SUPERIOR COURT OF ROCKDALE COUNTY STATE PDF form

1

IN THE SUPERIOR COURT OF ROCKDALE COUNTY

STATE OF GEORGIA

____________________________________ , §

Plaintiff, § Civil Action

Vs. § Case Number _______________

§

____________________________________ , §

Defendant. §

DOMESTIC RELATIONS FINANCIAL AFFIDAVIT

(1) Your Name:

Your Age:

Spouse’s Name:

Spouse’s Age:

Date of Marriage

Date of Separation:

Names and birth dates of children for whom support is to be determined in this action:

Name

Date of Birth

Resides with

Names and birth dates of your other children:

Name

Date of Birth

Resides with

(2) Summary of Your Income and Needs: (Fill out this part after you complete pages 2-5)

(A) Gross Monthly Income (from Item 3A below)

$

(B) Net Monthly Income (from Item 3B below)

$

(C) Average Monthly Expenses (Item 5A below)

$

Monthly Payments to Creditors (Item 5B below)

$

Total Monthly Expenses & Payments to Creditors (Item 5C below)

$

3.(A) YOUR GROSS MONTHLY INCOME: (Complete this section OR attach Child Support Schedule A.

All income must be entered based on monthly average regardless of date of receipt.

Where applicable, income should be annualized.)

Salary or Wages ---- Attach copies of 2 most recent pay-stubs or wage statements

$

Commissions, Fees & Tips

$

Income from Self Employment, partnership, close corporations & contracts

(gross receipts minus ordinary and necessary expenses required to produce income)

ATTACH SHEET ITEMIZING YOUR CALCULATIONS

$

Rental Income-(gross receipts minus ordinary and necessary expenses required to produce

income) ATTACH SHEET ITEMIZING YOUR CALCULATIONS

$

Bonuses / Overtime Payments

$

Severance Pay

$

Pension / Retirement Plan / Annuity

$

Disability / Unemployment / Worker’s Compensation

$

Social Security benefits (specify)

$

2

Other Public benefits ( specify )

$

Alimony / Spousal / Child support from prior marriage (specify)

$

Interest and dividends

$

Income from Trusts / Royalties / Estates

$

Capital Gains

$

Judgments from Personal Injury or other Civil Cases

$

Gifts (Cash or other gifts that can be converted to cash)

$

Fringe benefits such as: Automobile and/or auto allowance, insurance, ( auto, life

disability, etc.) deferred compensation, employer contribution to retirement or stock,

club memberships and reimbursed expenses ( to the extent they reduce personal living

expenses)

$

Any other income (Do not include TANF, food stamps or other public assistance)

$

GROSS MONTHLY INCOME (also write in 2A - page 1)

$

3.(B). Net Monthly Income From Employment

(deducting only state, federal taxes & FICA) (also write this total on line 2B on page 1)

$

Your Pay Period ( i.e. monthly, weekly, etc.):

No. of Exemptions Claimed by You: ______

(4). ASSETS

(List all assets here, including both marital and non-marital property. If you claim or agree that all or part of an asset is non-marital,

indicate the non-marital portion under the appropriate spouse’s column. The total value of each asset must be listed in the “value”

column. “Value” means what you feel the item of property would be worth if it were offered for sale.)

Description

Value

Separate Asset

of Husband

Separate

Asset of Wife

Basis of Claim

(pre-marital, gift, inheritance, etc.)

Cash

$

Stocks, Bonds

$

CD’s / Money Market Accounts

$

Bank Accounts (list each below)

$

1.

$

2.

$

3.

$

Retirement Pensions, 401 K, IRA or Profit-

Sharing

$

Money Owed to You or Spouse

$

Tax Refund Owed to You

$

Real Estate (list properties & mortgages):

$

Home

$

Debt owed on Home

$

Other Real Estate

Debt owed on Other Real Estate

$

Automobiles / Vehicles (list each vehicle and amount owed on each one):

(1.)

Debt owed in Vehicle (1)

(2.)

Debt owed in Vehicle (2)

Life Insurance

Furniture / Furnishings

Jewelry

Collectibles

Other Assets (specify):

TOTAL ASSETS

3

(5) (A) AVERAGE MONTHLY EXPENSES FOR YOU AND YOUR HOUSEHOLD

HOUSEHOLD

Mortgage or Rent Payments

$

Gas

$

Property Taxes

$

Repairs & Maintenance

$

Homeowner’s / Renter’s

Insurance

$

Lawn Care

$

Electricity

$

Pest Control

$

Water

$

Cable TV / Internet

Access

$

Garbage & Sewer

$

Misc. Household &

Grocery Items

$

Telephones

Meals Outside the Home

$

Home Phone

$

Other (specify)

$

Cellular Telephones

$

Sub Total $ ____________

AUTOMOTIVE

Gasoline & Oil

$

Tags / Registration &

License

$

Repairs & Maintenance

$

Insurance

$

Sub Total $ ____________

OTHER VEHICLES (boats, trailers, RV’s, etc.)

Gasoline & Oil

$

Tags / Registration &

License

$

Repairs & Maintenance

$

Insurance

$

INSURANCE

Health Insurance

$

Life Insurance

$

Children’s Portion

$

Relationship of

Beneficiary:

Dental Insurance

$

Disability Insurance

$

Children’s Portion

$

Other Insurance (specify)

$

Vision Insurance

$

Children’s Portion

$

Sub Total $ ____________

CHILDREN’S EXPENSES

Child Care (total monthly cost)

$

Allowance

$

School Tuition

$

Children’s Clothing

$

Tutoring

$

Diapers

$

Private Lessons (music, dance,

etc)

$

Medical / Dental/

Prescriptions

(out of pocket expenses)

$

School Supplies / Expenses

$

Grooming / Hygiene

$

Lunch Money

$

Children’s gifts to others

$

Other Education Expenses (list type & amount)

Entertainment

$

1.

$

Activities (extra-

curricular, school,

religious, cultural, etc.)

$

2.

$

Summer Camps

$

Sub Total $ ____________

4

YOUR OTHER EXPENSES

Dry Cleaning & Laundry

$

Publications (Magazines &

newspapers)

$

Clothing

$

Dues / Clubs

Medical / Dental / Prescription

(out of pocket expenses)

$

Religious / Charities

$

Your Gifts to Others (holidays)

$

Pet Expenses

$

Entertainment

$

Alimony Paid to a

Former Spouse

$

Recreational Expenses (fitness)

$

Child Support Paid for

other children

$

Vacations

$

Date of Initial Child

Support Order:

Travel Expenses for Visitation

$

Other (attach sheet if

necessary)

$

TOTAL of ABOVE EXPENSES (all sub-totals)

(also write on 1

st

line of 2C on page 1

$

(5)(B) YOUR PAYMENTS & DEBTS TO CREDITORS

To Whom

Balance

Due

Monthly

Payments

Joint

Husband or Wife (please

indicate)

$

Total Monthly Payments to Creditors (also write this total on line 2 of 2C on page 1)

$

(5)(C) TOTAL MONTHLY EXPENSES

(Total Expenses from final line on page 5 + Total Monthly Payments to Creditors above)

(also write this on line 3 of 2C on page 1)

$

_________________________________________ Name: __________________________

Signature (Plaintiff / Defendant) Pro Se Address: ________________________

[Sign in front of a notary public] ________________________________

Daytime Phone: ___________________

Sworn to and Subscribed before me this

day of , .

Notary Public

click to sign

signature

click to edit

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