in the court of common pleas division...2020/09/21 · uniform domestic relations form –...

Supreme Court of Ohio Uniform Domestic Relations Form – Affidavit 1 AFFIDAVIT OF BASIC INFORMATION, INCOME, AND EXPENSES Approved under Ohio Civil Rule 84 Amended: September 21, 2020 Page 1 of 7

IN THE COURT OF COMMON PLEAS ________________________ DIVISION ___________________ COUNTY, OHIO

Case No. ________________________

Judge ___________________________

Magistrate _______________________

_____________________________ Plaintiff/Petitioner 1

vs./and

_____________________________ Defendant/Petitioner 2

Instructions: Check local court rules to determine when this form must be filed. This affidavit is used to make complete disclosure of income, expenses, and money owed. It is used to determine child and spousal support. Do not leave any category blank. For each item, if none, put “NONE.” If you do not know exact figures for any item, give your best estimate, and put “EST.” If you need more space, add additional pages.

AFFIDAVIT OF BASIC INFORMATION, INCOME, AND EXPENSES

Affidavit of ___________________

Date of marriage ___________________ Date of separation ___________________

SECTION I – BASIC INFORMATION Plaintiff/Petitioner 1 Defendant/Petitioner 2

Date of Birth _____________________________ Date of Birth _____________________________

Social Security Number _____________________ Social Security Number _____________________

Phone Number ___________________________ Phone Number ___________________________ Health:

Good Fair Poor

If health is not good, please explain:

Health: Good Fair Poor

If health is not good, please explain:

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Education: (Check highest level achieved) Grade School High School Associate Bachelor’s Post Graduate

Education: (Check highest level achieved) Grade School High School Associate Bachelor’s Post Graduate

Other Technical Certifications:

Active Member of the U.S. Military Yes No

Other Technical Certifications:

Active Member of the U.S. Military Yes No

SECTION II – INCOME Plaintiff/Petitioner 1 Defendant/Petitioner 2

Yes No Yes No ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________

Employed Date of Employment

Name of Employer Payroll Address

Payroll City, State, Zip Scheduled Paychecks Per Year 12 24 26 52 12 24 26 52

A. YEARLY INCOME, OVERTIME, COMMISSIONS, AND BONUSES FOR PAST THREE YEARS

Plaintiff/Petitioner 1 Year $___________________ 3 years ago 20__

Base yearly income $___________________ 2 years ago 20__ $___________________ Last year 20__

Yearly overtime, commissions, and/or bonuses

$___________________ 3 years ago 20__ $___________________ 2 years ago 20__ $___________________ Last year 20__

Defendant/Petitioner 2 $ _________________ $ _________________ $ _________________

$ _________________$ _________________$ _________________

B. COMPUTATION OF CURRENT INCOME

Plaintiff/Petitioner 1 Defendant/Petitioner 2

$_________________ $_________________ Base Yearly Income

Average yearly overtime, commissions, and/or bonuses over last 3 years (from part A)

Supreme Court of Ohio Uniform Domestic Relations Form – Affidavit 1 AFFIDAVIT OF BASIC INFORMATION, INCOME, AND EXPENSES Approved under Ohio Civil Rule 84 Amended: September 21, 2020

$_________________ $_________________

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$_________________ $_________________ Unemployment Compensation Disability Benefits

Workers’ Compensation Social Security Other: ________________ $_________________ $_________________

Retirement Benefits Social Security Other: ________________ $_________________ $_________________

$_________________ $_________________

$_________________ $_________________

$_________________ $_________________

$_________________ $_________________

$_________________ $_________________

Spousal Support Received

Interest and dividend income (source) __________________

Other income (type and source) _________________________

TOTAL YEARLY INCOME

Supplemental Security Income (SSI) or public assistance

Court-ordered child support that you receive for minor and/or dependent child(ren) not of the marriage or relationship $_________________ $_________________

SECTION III – CHILDREN AND HOUSEHOLD RESIDENTS

Minor and/or dependent child(ren) who is/are adopted or born from this marriage or relationship:

Name __________________________ __________________________ __________________________ __________________________

Date of birth _________________ _________________ _________________ _________________

Living with ______________________ ______________________ ______________________ ______________________

In addition to the above child(ren): Plaintiff/Petitioner 1 has _________ other minor biological or adopted child(ren). Defendant/Petitioner 2 has _________ other minor biological or adopted child(ren). There is/are _________ adult(s) in your household.


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SECTION IV – EXPENSES

List monthly expenses below for your present household.

A. MONTHLY HOUSING EXPENSES

Rent or first mortgage (including taxes and insurance) $_________________ Second mortgage/equity line of credit $_________________ Real estate taxes (if not included above) $_________________ Renter or homeowner's insurance (if not included above) $_________________ Homeowner or condominium association fee $_________________ Utilities ° Electric $_________________

° Gas, fuel oil, propane $_________________ ° Water and sewer $_________________ ° Telephone and/or cell phone $_________________ ° Trash collection $_________________ ° Cable/satellite television $_________________ ° Internet service $_________________ Cleaning $_________________ Lawn service and/or snow removal $_________________ Other: _____________________________________________________ $_________________

_____________________________________________________ $_________________ TOTAL MONTHLY: $_________________

B. OTHER MONTHLY LIVING EXPENSES

Food ° Groceries (including food, paper, cleaning products, toiletries, and other) $_________________ ° Restaurant $_________________

Transportation ° Vehicle loan, lease $_________________ ° Vehicle maintenance $_________________ ° Gasoline $_________________ ° Parking, public transportation $_________________

Clothing

° Clothes (other than child(ren)’s)


$_________________

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° Dry cleaning and laundry $_________________ Personal grooming ° Hair and nail care $_________________ ° Other: ___________________________________________________ $_________________

Other: _____________________________________________________ $_________________ TOTAL MONTHLY: $_________________

C. MONTHLY MINOR CHILD-RELATED EXPENSES(for child(ren) of the marriage or relationship)

Work and/or education-related child care $_________________ Other child care $_________________ Extraordinary parenting time travel cost $_________________ School tuition $_________________ School lunches $_________________ School supplies $_________________ Extracurricular activities and lessons $_________________ Clothing $_________________ Child(ren)’s allowances $_________________ Special and extraordinary needs of child(ren) (not included elsewhere) $_________________ Other: _____________________________________________________ $_________________

TOTAL MONTHLY: $_________________

D. MONTHLY INSURANCE PREMIUMS

Life $_________________ Auto $_________________ Health $_________________ Disability $_________________ Other: _____________________________________________________ $_________________

TOTAL MONTHLY: $_________________

E. MONTHLY WORK AND EDUCATION EXPENSES FOR SELF

Mandatory work expenses (union dues, uniforms, or other) $_________________ Additional income taxes paid (not deducted from wages)


$_________________

Supreme Court of Ohio Uniform Domestic Relations Form – Affidavit 1 AFFIDAVIT OF BASIC INFORMATION, INCOME, AND EXPENSESApproved under Ohio Civil Rule 84 Amended: September 21, 2020

Page 6 of 7

Tuition $_________________ Books, fees, and other $_________________ College loan $_________________ Other: _____________________________________________________ $_________________

_____________________________________________________ $ _________________ TOTAL MONTHLY: $_________________

F. MONTHLY HEALTH CARE EXPENSES(not covered by insurance)

Physicians $_________________ Dentists and orthodontists $_________________ Optometrists and opticians $_________________ Prescriptions $_________________ Other: _____________________________________________________ $_________________

TOTAL MONTHLY: $_________________

G. MISCELLANEOUS MONTHLY EXPENSES

Extraordinary obligations for other minor/handicapped child(ren) [for child(ren) who were not born of this marriage or relationship and were not adopted by these parties] $_________________ Child support for child(ren) who were not born of this marriage or relationship and were not adopted by these parties $_________________ Expenses paid for adult child(ren) or other dependent(s) $_________________ Spousal support paid to former spouse(s) $_________________ Subscriptions and books $_________________ Charitable contributions $_________________ Memberships (associations and clubs) $_________________ Travel and vacations $_________________ Pets $_________________ Gifts $_________________ Attorney fees $_________________

$_________________ _____________________________________________________ $_________________

TOTAL MONTHLY: $_________________

Other:_____________________________________________________

Supreme Court of Ohio Uniform Domestic Relations Form – Affidavit 1 AFFIDAVIT OF BASIC INFORMATION, INCOME, AND EXPENSES Approved under Ohio Civil Rule 84 Amended: September 21, 2020 Page 7 of 7

H. MONTHLY INSTALLMENT PAYMENTS INCLUDING BANKRUPTCY PAYMENTS(Do not repeat expenses already listed.)Examples: car, credit card, rent-to-own, or cash advance payments

To whom paid Purpose Balance due Monthly payment __________________ __________________ __________________ $___________________ __________________ __________________ __________________ $___________________ __________________ __________________ __________________ $___________________ __________________ __________________ __________________ $___________________ __________________ __________________ __________________ $___________________ __________________ __________________ __________________ $___________________ __________________ __________________ __________________ $___________________ __________________ __________________ __________________ $___________________ __________________ __________________ __________________ $___________________ __________________ __________________ __________________ $___________________ __________________ __________________ __________________ $___________________ __________________ __________________ __________________ $___________________ __________________ __________________ __________________ $___________________

TOTAL MONTHLY: $___________________

GRAND TOTAL MONTHLY EXPENSES (Sum of A through H): $___________________

OATH OR AFFIRMATION (Do not sign until Notary Public is present)

I, (print name) ____________________, swear or affirm that I have read this Affidavit and, to the best of my knowledge and belief, the facts and information stated in this Affidavit are true, accurate, and complete. I understand that if I do not tell the truth, I may be subject to penalties for perjury.

___________________________________ Your Signature STATE OF ___________________ )

) SSCOUNTY OF _________________ )

Sworn to or affirmed before me by _____________________this _____day of ____________,______.

___________________________________ Signature of Notary Public

___________________________________ Printed Name of Notary PublicCommission Expiration Date: ___________(Affix seal here)

DIVISION: COUNTY OHIO: PlaintiffPetitioner 1: Case No: Judge: Magistrate: DefendantPetitioner 2: Affidavit of: Date of marriage: Date of separation: Date of Birth: Date of Birth_2: Social Security Number: Social Security Number_2: Phone Number: Phone Number_2: Good: OffFair: OffPoor: OffGood_2: OffFair_2: OffPoor_2: OffIf health is not good please explain: If health is not good please explain_2: Grade School: OffHigh School: OffAssociates: OffGrade School_2: OffHigh School_2: OffAssociates_2: OffBachelors: OffPost Graduate: OffBachelors_2: OffPost Graduate_2: OffOther Technical Certifications: Other Technical Certifications_2: 1: 2: 3: 4: 1_2: 2_2: 3_2: 4_2: 12: Off24: Off26: Off52: Off12_2: Off24_2: Off26_2: Off52_2: OffPlaintiffPetitioner 1_2: undefined_2: undefined_3: undefined_4: undefined_5: undefined_6: Workers Compensation: OffSocial Security: OffOther: OffSocial Security_2: OffOther_2: OffLawn service andor snow removal 1: To whom paid 1: To whom paid 2: To whom paid 3: To whom paid 4: To whom paid 5: To whom paid 6: To whom paid 7: To whom paid 8: To whom paid 9: To whom paid 10: To whom paid 11: To whom paid 12: To whom paid 13: Purpose 1: Purpose 2: Purpose 3: Purpose 4: Purpose 5: Purpose 6: Purpose 7: Purpose 8: Purpose 9: Purpose 10: Purpose 11: Purpose 12: Purpose 13: Balance due 1: Balance due 2: Balance due 3: Balance due 4: Balance due 5: Balance due 6: Balance due 7: Balance due 8: Balance due 9: Balance due 10: Balance due 11: Balance due 12: Balance due 13: undefined_8: 0Text2: Text3: Text4: Text5: Text6: Text7: Text8: Text9: Text10: Text11: Text12: Text13: Text14: Text15: Text16: Text17: Text18: Text19: Text20: Text21: Text22: Text23: Text24: 0Text25: 0Text26: Text27: Text28: Text29: Text1: Text30: Text31: Text32: Text33: Text34: Text35: Text36: Text37: Text38: Text39: Text40: Text41: Text42: Text43: Text44: Text46: Text47: Text48: Text49: Text50: Text51: Text52: Text53: Text54: Text55: Text56: Text57: Text58: Text59: Text62: Text63: Text64: Text65: Text66: Text67: Text68: Text69: Text70: Text71: Text72: 0Text74: Text75: Text77: Text78: Text79: Text80: Text82: Text83: Text85: Text86: Text87: Text88: 0Text89: Text90: Text91: Text92: Text93: Text94: Text95: Text96: Text97: Text98: Text99: Text100: 0Text101: Text102: Text103: Text104: Text105: Text106: 0Text107: Text108: Text109: Text110: Text111: Text112: Text113: Text114: 0Text115: Text116: Text117: Text118: Text119: Text120: 0Text121: Text122: Text123: Text124: Text125: Text126: Text127: Text128: Text129: Text130: Text131: Text132: Text133: Text134: 0Text136: Text137: Text138: Text139: Text140: Text141: Text142: Text143: Text144: Text145: Text146: Text147: Text148: Text149: 0Check Box150: OffCheck Box151: OffCheck Box152: OffCheck Box153: OffText155: Text156: Text157: Text158: Text159: Text160: Check Box161: OffCheck Box162: OffCheck Box163: OffCheck Box164: Offother minor andor dependent children: Text45: Text61:

in the court of common pleas division...2020/09/21 · uniform domestic relations form –...

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