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This form is approved by the Illinois Supreme Court and is required to be used in all Illinois Circuit Courts.
STATE OF ILLINOIS,
CIRCUIT COURT
COUNTY
FINANCIAL AFFIDAVIT
(FAMILY & DIVORCE CASES)
Pre-Judgment
Post-Judgment
For Court Use Only
Instructions
Petitioner (First, middle, last name)
v.
Respondent (First, middle, last name)
Enter above the
county name where
the case was filed.
Enter name of the
Petitioner, the
Respondent, and the
case number as listed
in the initial Petition
or Complaint.
Case Number
Enter the Case
Number given by the
Circuit Clerk.
IMPORTANT: (1) If you intentionally or recklessly enter inaccurate or misleading information on this form, you may face
significant penalties and sanctions, including costs and attorney's fees; (2) If you need more room for a section, complete
and attach the Additional Information form for that section. Do not file this document and the enclosures with the Circuit
Clerk unless a local rule or court order requires you to do so. Ask the Circuit Clerk where to find these rules.
NOTE: Do not include
in this affidavit any
Social Security or
individual taxpayer-
identification numbers,
driver's license
numbers, financial
account numbers, or
debit or credit card
numbers. If any of
these items are
included on documents
you are going to attach
to this affidavit, hide
them by covering them
with black ink or
otherwise removing.
In 3a-d, check the
boxes of the
documents you are
attaching to this form
as evidence of your
income, assets, and
debts. If you select 3d,
enter the names of the
additional documents
you are attaching.
In 4, do not complete
4b and 4c if your
contact information is
protected pursuant to
court order because of
domestic violence or
abuse.
1.
I am the
Petitioner
Respondent in this case.
2.
I swear or affirm the information in this Financial Affidavit and all attached statements
are true and correct as of
.
Date
3.
I attached the most recent copies of the following documents (Check all that apply. You
must attach these documents if you have or can get them.)
a.
pay stubs or other proof of income
b.
income tax returns (including K-1, W-2, 1099, and all schedules.)
c.
bank statements
d.
other documents in verifying your debts in 14 and your assets in 15:
4.
Information about myself
a.
Name
First
Middle
Last
b.
Phone Number
c.
Home Address
Street Address, Apt.
City
State
ZIP
d.
Date of Birth
5.
Information about other household members
I live with another adult who helps me pay my expenses. This person is not the Petitioner
or Respondent in this case.
Yes
No
DV-A 120.3
Page 1 of 10
(06/21)
Enter the Case Number given by the Circuit Clerk: _________________________________
6.
My Employment/Business
a.
I am
unemployed
b.
I am
employed by someone else
Employer name
In 6, check all that
apply. Provide all
information
requested about your
jobs, including all
full-time, part-time,
temporary, contract,
or other work.
Provide all the
requested
information about
any business you
own or operate and
the business income.
If you have more
than one job or
business, fill out and
attach the Additional
My Employment/
Business forms.
In 6b, enter your
total gross income
from this employer
from January 1 of
this year through the
date you complete
this form.
In 6c, check the box
that best describes
your self-
employment, and/or
the box that
describes the type of
business you have.
List the name and
address of the
business, and the
gross receipts for
last year and this
year.
Employer address
Street Address, Apt.
City
State
ZIP
Number of paychecks per year:
12 (monthly)
24 (two times a month)
26 (every two weeks)
52 (weekly)
I am paid in cash
Gross income (pay before taxes and deductions) so far this year
$
as of
.
Date
c.
Self-Employment or Other Business Income:
own a business as a sole proprietorship.
as an independent contractor.
as a member of a partnership.
as a member of a limited liability company (LLC) not treated as a
corporation.
closely held corporation.
other flow-through business entity.
Business name:
Business address:
Street Address, Apt.
City
State
ZIP
Gross business receipts for last year
$
and so far this year
$
Ordinary and necessary expenses required to carry on the business for
this year
$
and last year
$
Do you receive any of the following from the business (check all that apply):
Reimbursed meals
Company car
Free housing or housing allowance
Other:
(You must attach complete federal and state business tax returns for the most recent tax year.)
I have attached one or more Additional My Employment/Business forms.
DV-A 120.3
Page 2 of 10
(06/21)
Enter the Case Number given by the Circuit Clerk: _________________________________
In 7a, check only
one.
In 7a-e, enter the
information you
submitted on last
year's IRS tax return.
If you did not file a
tax return for last
year, check Did not
file in 7a, leave 7b-d
blank, but still
complete 7e.
For help in
calculating monthly
amounts, see How to
Complete a Financial
Affidavit (Family &
Divorce Cases).
In 8, Regular
employment
earnings mean the
monthly gross
income you receive
on a regular basis
from employment.
If you have other
income not listed in
8, describe the source
of the income in
Other and enter the
monthly amount.
In Total Gross
Monthly Income,
add the amounts in 8
together and enter the
total.
7.
My gross income and taxes from last year
a.
Tax filing status
Married (Joint)
Head of Household
b.
Number of dependent exemptions claimed
Married (Separate)
Single
Did not file
c.
Total number of exemptions claimed
d.
I claim on my federal tax return
the standardized deduction
itemized deductions
e.
Gross income (before taxes and deductions) last year
$
8.
My monthly gross income from all sources
Regular employment/self-employment earnings from all jobs (salary, wages,
base pay, etc)………………………………………………………………………………
Overtime………………………………………………………………………..…
Commission………………………………………………………………………
Tips………………………………………………………………………………..
Bonus…..…………………………………………………………………………
Pension………………………………………………………………………..….
Annuity…………………………………………………………………………….
Interest income…………………………………………………………………...
Dividend income………………………………………………………………….
Trust income………………………………………………………………………
Social Security Retirement ……………………………………………………..
Social Security Disability………………………………………………………..
Social Security Income (SSI) (not included as income for child support purposes)
Unemployment……………………………………………………………………
Disability payment (not Social Security)………………………………………….
Workers' Compensation…………………………………………………………
TANF and SNAP (not included as income for child support purposes)………….
Military allowances……………………………………………………………….
Investment income……………………………………………………………….
Rental income…………………………………………………………………….
Partnership income………………………………………………………………
Distributions and draws………………………………………………………….
Royalty income…………………………………………………………….……..
Maintenance received under an order entered in this case or another case
that you must report as income on your tax return …………………………..
Maintenance received under an order entered in this case or another case
that you do not have to report as income on your tax return…………………
Child support for children of this relationship (if this support is paid by the other
parent, it does not affect the support calculation)……………….………………….
Social Security payment made to the children of this relationship based on
your disability or retirement……………………………………………………..
Gifts of money……………………………………………………………………
Other:
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Total Gross Monthly Income
$
DV-A 120.3
Page 3 of 10
(06/21)
0.00
Enter the Case Number given by the Circuit Clerk: _________________________________
In 9, use information
from your paystubs, tax
records, and other
sources to identify the
deductions being taken
from your income. List
money deducted for
health insurance below
in Section 13.
In Total Monthly
Deductions, add the
amounts from 9
together and enter the
total.
In 10, list any
maintenance payments
you are making. If you
are not sure about
whether your payments
are tax-deductible,
speak to your attorney
or tax-preparer.
Generally, maintenance
payments court ordered
after January 1, 2019
are not tax deductible.
For 11, attach a copy of
the support order and
proof that you are
making the payments,
e.g. cancelled checks,
court records.
9.
My monthly payroll deductions
Federal tax……………………………………………………………………......
State tax………………………………………………………………………......
FICA (or Social Security equivalent, for example, Self-employment) tax)…………
Medicare tax……………………………………………………………………...
Mandatory retirement contributions (by law or condition of employment, but
only if no FICA or Social Security equivalent)………………………………………
Total Monthly Deductions
10.
Monthly maintenance payments
Maintenance being paid or payable to the other party by you under a court
order in this case…………………………………………………………………
Maintenance being paid under a court order to a former spouse by you,
which is tax deductible to you…………………………………………………..
Maintenance being paid under a court order to a former spouse by you,
which is not tax deductible to you……………………………………………...
Total Maintenance Payments
11.
Monthly child Support payments
Child support being paid for the children of this relationship under a
court order in this case or a different case……………………………………
Child support being paid under a court order for children not shared with
the other party and who are not part of this case…………………………….
Child support being paid, but there is no court order, for children not
shared with the other party and who are not part of this case and (1)
that are presumed to be yours, (2) for whom there is a voluntary
acknowledgment of paternity (VAP) signed by you and the other parent,
OR (3) for whom there is a court order naming you as a parent, but there is
no support order………………………………………………………………….
Total Child Support Payments
12.
My monthly Living Expenses
a.
Household Expenses
Mortgage or rent………………………………………………………………….
Home equity (HELOC) and second mortgage……………………….…………
Real estate taxes………………………………………………………..............
Homeowners or condo association dues and assessments…………..........
Homeowners or renters insurance……………………………………………..
Gas……………………………………………………………………….......…...
Electric…………………………………………………………………………….
Telephone…………………………………………………………………………
Cable or satellite TV……………………………………………………………..
Internet………………………………………………………………………….…
Water and sewer………………………………………………………..………..
Garbage removal……………………………………………………….………..
Laundry and dry cleaning……………………………………….………………
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
For help in calculating
monthly amounts, see
How to Complete a
Financial Affidavit.
In 12a, enter the
amount your household
spends on each item
each month.
If you have other living
expenses not listed in
12a, describe the
expense in Other and
enter the monthly
amount.
DV-A 120.3
Page 4 of 10
(06/21)
0.00
0.00
0.00
Enter the Case Number given by the Circuit Clerk: _________________________________
House cleaning service………………………………………………………….
$
$
In Subtotal Monthly
Necessary repairs and maintenance to my property…………………………
Household Expenses,
$
Pet care………………..………………………………………………………….
add the amounts in 12a
$
Groceries, household supplies, and toiletries…………………………………
together and enter the
total.
$
Other:
DV-A 120.3
Page 5 of 10
(06/21)
Subtotal Monthly Household Expenses
b.
Transportation Expenses
Car payment………………………………………….…………………………..
Repairs and maintenance………………………………………………………
Insurance, license, registration and city sticker………………………………
Gasoline……...…………………………………………………………….........
Taxi, ride-share, bus, and train………………………………………………...
Parking……………………………………………………………………………
Other:
Subtotal Monthly Transportation Expenses
c.
Personal Expenses
Medical (out-of-pocket expenses)
Doctor visits……………………………………………………….
Therapy and counseling…………………………………………
Dental and orthodontia…………………………………………..
Optical……………………………………………………………..
Medicine…………………………………………………………..
Life insurance
Life (term)………………………………………………………….
Life (whole or annuitty)……………………………………………..
Clothing…………………………………………………………………………...
Grooming (hair, nails, spa, etc.)......................................................................
Gym & Club membership Dues………………………………………………..
Entertainment, dining out, and hobbies………………………………………
Newspapers, magazines, and subscriptions…………………………………
Gifts…….…………………………………………………………………………
Donations (political, religious, charity, etc.)………………………………………
Vacations…………………………………………………………………..…….
Mandatory or voluntary union, trade or professional association dues……
Professional fees (accountants, tax preparers, attorneys)…………….………..
Other:
Subtotal Monthly Personal Expenses
d.
Minor and Dependent Children Expenses
Clothing…………………………………………………………………………...
Grooming (hair, nails, spa, etc.)………………………………………………….
Education
Tuition……………………………………………………………….
Books, fees, and supplies…………………………………………
School lunch………………………………………………………..
Transportation………………………………………………………
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
In 12b, enter the
amount you spend
monthly on each type of
transportation expense.
If you have other
transportation expenses
not listed in 12b,
describe the expense in
Other and enter the
monthly amount.
In Subtotal Monthly
Transportation
Expenses, add the
amounts in 12b together
and enter the total.
In 12c, enter the amount
you spend monthly only
for yourself on each
type of expense. Do not
include expenses you
are reimbursed for
through insurance or
your employer.
If you have other
personal expenses not
listed in 12c, describe
the expense in Other
and enter the monthly
amount.
In Subtotal Monthly
Personal Expenses,
add the amounts in 12c
together and enter the
total.
In 12d, enter the
amount spent monthly
for the minor and
dependent children of
this relationship only.
0.00
0.00
0.00
Enter the Case Number given by the Circuit Clerk: _________________________________
In Medical, do not
include expenses you
are reimbursed for
through insurance or
your employer.
If there are other child-
related expenses not
listed in 12d, describe
the expense in Other
and enter the amount.
In Subtotal Monthly
Minor and Dependent
Children Expenses,
add the amounts in 12d
together and enter the
total.
In 13, enter information
about the primary
health insurance you
have for yourself and
your family.
If you have more than
one Health Insurance
carrier, then list other
health insurance
company in the
Additional Health
Insurance forms and
attach it.
School-sponsored trips and special events……………………..
Uniforms…………………………………………………….……….
Before and after-school care……………………………….……..
Tutoring and summer school……………………………….……..
Medical (out-of-pocket expenses)
Doctor visits………………………………………………………...
Therapy and counseling ………………………………………….
Dental and orthodontia …………………………………………...
Optical……………………………………………………………….
Medicine…………………………………………………………….
Allowance…………………………………………………………………………
Childcare and sitters…………………………………………………………….
Extracurricular activities and sports (including equipment, uniforms, etc.)……
Summer and school-break camps……………………………………………..
Vacations (children only)………………………………….…...…………………
Entertainment, dining out, and hobbies (children only)………….…………….
Gifts children give to others…………………….………………………..……..
Other:
Subtotal Monthly Minor and Dependent Children Expenses
Total Monthly Living Expenses (add the subtotals from 12a-d above)
13.
Health Insurance
I have health insurance:
Yes
No
The insurance company is:
The type of insurance is:
Medical
Dental
Optical
Deductible: Per individual
$
Per family
$
It covers:
Me
My spouse/partner
My dependents
Type of Policy:
HMO
PPO
Other
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Provided by:
Employer
Private Policy
Other Group
Medicaid/All Kids
Monthly cost is paid by:
Me
My spouse
Other
Total number of people covered by this policy:
The amount I pay monthly for insurance for children of this relationship:
The amount I pay monthly for deductibles, co-insurance, and co-payments
for the children of this relationship:
Total Monthly Health Insurance Cost
I have attached one or more Additional Health Insurance forms.
$
$
$
DV-A 120.3
Page 6 of 10
(06/21)
0.00
0.00
0.00
I I
~
~11
__
_______,
11
Enter the Case Number given by the Circuit Clerk: _________________________________
In 14, enter your debts
14.
My Debts (do not list expenses included in section 12)
including credit cards
and past due bills. Do not
include debt payments
previously listed in 12
and 13 above, such as
your mortgage or car
payment.
If you have more than 4
creditors, list them on
Additional My Debts
forms and attach them.
In Total Monthly Debt
Payments, add the
Monthly Payment
amounts from 14
together and enter the
total. Include any debts
listed on any Additional
My Debts forms.
Creditor Name
Describe Nature of Debt (parking
tickets, household goods, attorney's
fees, etc.)
Amount
Owed
Monthly
Payment
Being
Made
1.
$
$
2.
$
$
3.
$
$
4.
$
$
5.
$
$
6.
$
$
I have attached one or more Additional My Debts forms.
Amount from Additional My Debts (if any)
$
Total Monthly Debt Payments
$
Note:
Fair Market Value (FMV) is generally defined as a selling price for an item to which an unrelated buyer
and seller can agree. For more information on FMV, read How to Complete a Financial Affidavit (Family
& Divorce Case) available at https://www.illinoiscourts.gov/documents-and-forms/approved-forms/.
In 15a, enter your cash
and cash equivalents.
Do not list account
numbers.
If you have more than 4
Checking, Savings,
Money Market or
Other Bank or Credit
Union Accounts, list
them in Additional Cash
and Cash Equivalents
forms and attach them.
15.
My Assets
a.
Cash and Cash Equivalents (list balance as of the date of this affidavit)
Checking, Savings, Money Market, and Other Bank or Credit Union Accounts
Name of Bank or Institution
Name on Account
Account Type
Balance
1.
$
2.
$
3.
$
4.
$
I have attached one or more Additional Cash and Cash Equivalents forms.
Certificates of Deposit (list balance as of the date of this affidavit)
If you have more than 3
Certificates of Deposit,
list them in Additional
Certificates of Deposit
forms and attach them.
Name of Bank or Institution
Name on Account
Balance
1.
$
2.
$
3.
$
I have attached one or more Additional Certificates of Deposit forms.
A Prepaid Debit Card
is a card that can be used
Cash and Prepaid Debit Cards (list balance as of the date of this affidavit)
to make purchases much
as you would use cash.
Many prepaid cards
carry the brand of a card
network, like
MasterCard, Visa, or
American Express.
I have attached one or more Additional Cash and Prepaid Debit Card forms.
If you have more than 3
Cash or Prepaid Debit
Cards or locations for
your cash, list them in
Additional Cash and
Prepaid Debit Card
forms and attach them.
Location of Cash/Card
Held By
Balance
1.
$
2.
$
3.
$
DV-A 120.3
Page 7 of 10
(06/21)
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11
I I I
f--------------
11
>--------------
>---------+----11
-------
11
Enter the Case Number given by the Circuit Clerk: _________________________________
b.
Investment Accounts and Securities (list FMV or balance as of the date of this affidavit)
Stocks, Bonds, Options, Employee Stock Ownership Plans
In 15b, enter
information for your
investments and
securities.
If you have more than 3
Investment Accounts
and Securities, list them
in Additional Investment
Accounts and Securities
forms and attach them.
If you have more than 3
Investment/Brokerage
Accounts, Mutual
Funds, and Secured or
Unsecured Notes, list
them in Additional
Investment/Brokerage
Accounts, Mutual
Funds, and Secured or
Unsecured Notes forms
and attach them.
In 15c, enter information
for your real estate,
including your home if
you own it.
If you have more than 3
pieces of Real Estate,
list them in Additional
Real Estate forms and
attach them.
In 15c and 15d, in
Balance Due, enter the
total amount remaining
on your loan.
In 15d, enter
information about your
motor vehicles.
If you have more than 4
Motor Vehicles, list
them in Additional
Motor Vehicles forms
and attach them.
In 15e, enter information
about your business
interests. In Type of
Business, enter whether
the business is a
corporation, S Corp, or
LLC, etc.
If you have more than 3
Business Interests, list
them in Additional
Business Interests forms
and attach them.
Company Name
# Shares
Type
Owner
FMV
1.
$
2.
$
3.
$
I have attached one or more Additional Investment Accounts and Securities forms.
Investment/Brokerage Accounts, Mutual Funds, and Secured or Unsecured Notes (list
balance as of the date of this affidavit)
Description of Asset
Owner
Balance
1.
$
2.
$
3.
$
I have attached one or more Additional Investment/Brokerage Accounts, Mutual Funds,
and Secured or Unsecured Notes forms.
c.
Real Estate (list FMV and balance due as of the date of this affidavit)
Address
Name on Title
FMV
Balance Due
1.
$
$
2.
$
$
3.
$
$
I have attached one or more Additional Real Estate forms.
d.
Motor Vehicles (cars, boats, trailers, motorcycles, aircrafts, etc.) (list FMV and balance due as of
the date of this affidavit)
Year, Make, and Model
Name on Title
FMV
Balance Due
1.
$
$
2.
$
$
3.
$
$
4.
$
$
I have attached one or more Additional Motor Vehicles forms.
e.
Business Interests (list FMV as of the date of this affidavit)
Name of Business
Type of Business
% of Ownership
FMV
1.
$
2.
$
3.
$
I have attached one or more Additional Business Interests forms.
DV-A 120.3
Page 8 of 10
(06/21)
t--------------
t-----+-----11
----------
t--------------
1---------+----I
I
----------
>--------------
1---------+----I
I
----------
11
Enter the Case Number given by the Circuit Clerk: _________________________________
f.
Life Insurance Policies (list cash balance as of the date of this affidavit)
Name of Insurance Company
Type of Policy
Death Benefit
Cash Value
1.
$
$
2.
$
$
3.
$
$
In 15f, enter information
about each life insurance
policy you have for
yourself, the other party,
or your children.
If you have more than 3
Life Insurance Policies,
list them in Additional
Life Insurance Policies
forms and attach them.
In 15g, enter information
about retirement benefits
(vested and non-vested).
If you have more than 4
Retirement Benefits
and Deferred
Compensation plans,
list them in Additional
Retirement Benefits and
Deferred Compensation
forms and attach them.
In 15h, enter
information for valuable
collectible items.
If you have more than 2
Valuable Collectibles,
list them in Additional
Valuable Collectibles
forms and attach them.
In 15i, enter information
for other personal
property with fair
market value over $500.
If you have more than 2
items of Personal
Property Valued Over
$500, list them in
Additional Other
Personal Property
Valued over $500 forms
and attach them.
In 15j, enter information
for assets or property
you transferred or sold
in the last 2 years with
FMV of at least $1,000.
Do not include income
items listed above in 8.
If you have sold or
transferred more than 2
Assets or Properties
Within the Last 2
Years With a FMV of
at Least $1,000, list
them in Additional
Transfer or Sale of
Assets or Property
Within the Last 2 Years
with a FMV of at least
$1,000 forms and attach
them.
I have attached one or more Additional Life Insurance Policies forms.
g.
Retirement Benefits and Deferred Compensation (pension plan, annuity, IRA, 401(k), 403(b), SEP)
(list FMV and or account balance as of the date of this affidavit)
Name of Plan
Type of Plan
FMV or Account
Balance
1.
$
2.
$
3.
$
4.
$
I have attached one or more Additional Retirement Benefits and Deferred Compensation
forms.
h.
Valuable Collectibles (coins, stamps, art, antiques, etc.)
Description
FMV
1.
$
2.
$
I have attached one or more Additional Valuable Collectibles forms.
i.
Other Personal Property Valued Over $500
Description
FMV
1.
$
2.
$
I have attached one or more Additional Other Personal Property Valued over $500 forms.
j.
Transfer or Sale of Assets or Property Within the Last 2 Years With a FMV of at Least $1,000
Description
Transferred or Sold to
Date of
Transfer
Amount
1.
$
2.
$
I have attached one or more Additional Transfer of Sale of Assets or Property Within the
Last 2 Years With a FMV of at Least $1,000 forms.
DV-A 120.3
Page 9 of 10
(06/21)
In 16, enter information
about lawsuits and
claims you have filed or
have been filed against
you. If you did not
recover anything, enter
$0. If your case is still
pending or has not yet
been filed, enter
unknown.
If you have more than 3
Lawsuits and Claims,
list them in Additional
Lawsuits and Claims
forms and attach them.
In 17, enter information
about your federal and
state tax returns for the
last 2 years. Check
Refund if you received
money or a check, or
Amount Owed if you
owed additional taxes.
Enter the Case Number given by the Circuit Clerk: _________________________________
16.
Lawsuits and Claims (workers' compensation, disability, etc.)
Case Number
Date Lawsuit or Claim Filed
Amount Recovered
1.
$
2.
$
3.
$
I have attached one or more Additional Lawsuits and Claims forms.
17.
Income Tax Refunds or Amounts Owed for the Last 2 Years (federal and state)
Tax year
Federal
State
1.
Refund
$
Amount Owed
$
Refund
Amount Owed
$
$
2.
Refund
$
Amount Owed
$
Refund
Amount Owed
$
$
IMPORTANT: If you intentionally or recklessly enter inaccurate or misleading information on this form, you may face
significant penalties and sanctions, including costs and attorney's fees.
Under the Code of
Civil Procedure, 735
ILCS 5/1-109,
making a statement
on this form that you
know to be false is
perjury, a Class 3
Felony.
After you finish this
form, sign and print
your name and date it.
I certify that everything in the Financial Affidavit is true and correct. I understand that
making a false statement on this form is perjury and has penalties provided by law under
735 ILCS 5/1-109.
Your Signature
Your Name
Date
DV-A 120.3
Page 10 of 10
(06/21)
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Completed 20 August 2021

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