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IN THE SUPERIOR COURT OF ROCKDALE COUNTY STATE

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Rockdale Judicial Circuit
Page 1 of 7
IN THE SUPERIOR COURT OF ROCKDALE COUNTY
STATE OF GEORGIA
)
, Plaintiff )
)
vs. ) Civil Action No.
)
, Defendant )
)
DOMESTIC RELATIONS FINANCIAL AFFIDAVIT
1. AFFIANT’S NAME: Age
Spouse’s Name: Age
Date of Marriage: Date of Separation
Names and birth dates of children for whom support is to be determined in this action:
Name Year of Birth Resides with
Names and birth dates of affiant’s other children:
Na
me Year of Birth Resides with
2. SUMMARY OF AFFIANT’S INCOME AND NEEDS
(a) Gross monthly income (from item 3A) $
(b) Net monthly income (from item 3B) $
(c) Average monthly expenses (item 5A) $
Monthly payments to creditors +
Total monthly expenses and payments
to creditors (item 5C) $
Rockdale Judicial Circuit
Page 2 of 7
3. A. AFFIANT’S 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.)
Salary or Wages $
ATTACH COPIES OF 2 MOST RECENT WAGE STATEMENTS
Commissions, Fees, Tips $
Income from self-employment, partnership, close corporations,
and independent 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 $
Recurring Income from Pensions or Retirement Plans $
Interest and Dividends $
Trust Income $
Income from Annuities $
Capital Gains $
Social Security Disability or Retirement Benefits $
Workers’ Compensation Benefits $
Unemployment Benefits $
Judgments from Personal Injury or Other Civil Cases $
Gifts (cash or other gifts that can be converted to cash) $
Prizes/Lottery Winnings $
Alimony and maintenance from persons not in this case $
Assets which are used for support of family $
Fringe Benefits (if significantly reduce living expenses) $
Rockdale Judicial Circuit
Page 3 of 7
Any other income (do NOT include means-tested
Public assistance, such as TANF or food stamps) $
GROSS MONTHLY INCOME $
B. Affiant’s Net Monthly Income from employment
(deducting only state and federal taxes and FICA) $
Affiant’s pay period (i.e., weekly, monthly, etc.)
Number of exemptions claimed
4. ASSETS
(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 and state the amount and the basis: pre-marital, gift, inheritance, source of
funds, etc.).
Description
Value
Separate Asset
of the Husband
Separate Asset
of the Wife
Basis of the
Claim
Cash $
Stocks, bonds $
CD’s/Money Market
Accounts
$
Bank Accounts
(list each account):
ONLY LIST LAST
FOUR DIGITS OF
ACCOUNT
$
$
$
Retirement Pensions,
401K, IRA, or
Profit Sharing
$
Money owed you: $
Tax Refund
owed you:
$
Rockdale Judicial Circuit
Page 4 of 7
Real Estate:
home:
debt owed:
$
$
other:
debt owed:
$
$
Automobiles/Vehicles:
Vehicle 1:
debt owed:
$
$
Vehicle 2:
debt owed:
$
$
Life Insurance
(net cash value):
$
Furniture/furnishings: $
Jewelry: $
Collectibles: $
Other Assets: $
$
$
$
Total Assets:
$
5. A. AVERAGE MONTHLY EXPENSES
HOUSEHOLD
Mortgage or rent payments
$
Cable TV
$
Property taxes
$
Misc. household and grocery
Items
$
Homeowner/Renter Insurance $
Meals outside the home $
Electricity
$
Other
$
Rockdale Judicial Circuit
Page 5 of 7
Water
$
AUTOMOBILE
Gasoline and oil
$
Garbage and Sewer
$
Telephone:
residential line:
cellular telephone:
$
$
Repairs
Auto tags and license
Insurance
$
$
$
Gas $
OTHER VEHICLES
(boats, trailers, RVs, etc.)
Gasoline and oil
$
Repairs and maintenance:
$
Repairs
$
Lawn Care
$
Pest Control
$
Tags and license
Insurance
$
$
CHILDREN’S EXPENSES
AFFIANT’S OTHER EXPENSES
Child care (total monthly cost) $ Dry cleaning/laundry $
School tuition $ Clothing $
Tutoring
Private lessons (e.g., music, dance)
$
$
Medical, dental, prescription
(out of pocket/uncovered expenses)
Affiant’s gifts (special holidays)
$
$
School supplies/expenses $ Entertainment $
Lunch Money $ Recreational Expenses (e.g.,
fitness)
$
Other Educational Expenses (list)
Vacations $
$
Travel Expenses for Visitation
$
$
Publications
$
Allowance
$
Dues, clubs
$
Clothing $ Religious and charities $
Diapers $ Pet expenses $
Medical, dental, prescription
(out of pocket/uncovered expenses)
$
Alimony paid to former spouse $
Rockdale Judicial Circuit
Page 6 of 7
Grooming, hygiene $
Child support paid for other
children
$
Gifts from children to others $ Date of initial order:
Entertainment $ Other (attach sheet) $
Activities (including extra-curricular,
school, religious, cultural, etc.)
$
Summer Camps
$
OTHER INSURANCE
Health
Child(ren)’s portion:
$
$
Dental
Child(ren)’s portion:
$
$
Vision
Child(ren)’s portion:
$
$
Life
Relationship of
Beneficiary:
$
Disability $
Other(specify):
$
TOTAL ABOVE EXPENSES $
B. PAYMENTS TO CREDITORS
(please check one)
To Whom:
Balance Due
Monthly
Payment
Joint
Plaintiff
Defendant
Rockdale Judicial Circuit
Page 7 of 7
TOTAL MONTHLY PAYMENTS TO CREDITORS: $
C. TOTAL MONTHLY EXPENSES: $
Personally appeared before me, an officer authorized to administer oaths, the undersigned affiant,
who upon being sworn, swears that he/she is legally competent to make this affidavit, that the
affidavit is based upon personal knowledge, and that the contents of the affidavit are true.
Affiant
Sworn to and subscribed before me, this day of , 20 .
Notary Public ___________________________________
M
y commission expires: ___________________________
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IN THE SUPERIOR COURT OF ROCKDALE COUNTY STATE

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Completed 11 April 2022

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