Office of Dispute Resolution
SEVENTH
JUDICIAL ADMINISTRATIVE DISTRICT
P.O.
www.7jad.com FAX: (770) 387-5479
IN THE SUPERIOR COURT OF
___________COUNTY
STATE OF
____________________, *
*
Plaintiff, *
* Civil Action
Vs. * File No.__________________
*
____________________, *
*
Defendant, *
DOMESTIC RELATIONS
FINANCIAL AFFIDAVIT
1. Affiant’s
Name ________________________________ Age:
_____________
Affiant’s
Social Security No. __________________________________________
Spouse’s
Name: _______________________________ Age:______________
Date of Marriage: _________________ Date of Separation: ______________
Names and birthdates of children of
this marriage:
Name Date of Birth Resides With
_____________________
_________________ ___________________
_____________________ _________________ ___________________
Names and birthdates of children of prior marriage(s) residing with Affiant:
Name Date 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 3C) $____________________
(c) Average monthly expenses (Item 5A) $____________________
Monthly payments to creditors (Item 5B) +____________________
Total monthly expenses and payments
To creditors (Item 5C) $____________________
(d) Amount of spousal / child
support needed
by Affiant $____________________
(e) Amount of child support
indicated by
Child Support Guidelines $____________________
3. A. Affiant’s Gross Monthly Income:
(All
income must be entered based on monthly average
regardless
of date of receipt. Where applicable,
income
should
be annualized).
Salary $____________________
Bonuses,
commissions, allowances, overtime, tips and
Similar
payments (based on past 12 month average or
Time
of employment if less that a year).
ATTACH
SHEETS ITEMIZING
THIS INCOME, ____________________
Business
income from sources such as self employment,
Partnership, close corporations, and/or
independent
Contracts (gross receipts minus ordinary and
necessary
Expenses required to produce income), ATTACH
SHEET
ITEMIZING
THIS INCOME. _____________________
Disability
/ unemployment, / worker’s comp _____________________
Pension,
retirements or annuity payments _____________________
Other
public benefits (specify) _____________________
Social
Security benefits _____________________
Spousal
or child support from prior marriage _____________________
Interest
and dividends _____________________
Rental
income (gross receipts minus ordinary and
Necessary expenses required to produce
income)
ATTACH
SHEET ITEMIZING THIS INCOME _____________________
Income
from royalties, trusts or estate _____________________
Gains
derived from dealing in property (not including
Non-recurring gains). _____________________
Other
income of a recurring nature (specify source) _____________________
GROSS
MONTHLY INCOME $_
_ _ _ _ _ _ _ _ _ _ _ _ _
B. List and describe all
benefits of employment, e.g., 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).
ATTACH SHEET, IF NECESSARY.
____________________________________________________________________
C. 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 in 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 Separate
Asset
of Husband of Wife
Cash $_____________ _____________ _____________
Stocks, bonds $_____________ _____________ _____________
CDs/Money Mkt Accts
$______________ _____________ _____________
Real Estate:
Home $_____________ _____________ _____________
Other $_____________ _____________ _____________
$_____________ _____________ _____________
Automobile $_____________ _____________ _____________
Money Owed You $_____________ _____________ _____________
Retirement/IRA $_____________ _____________ _____________
Furniture/furnishings $_____________ _____________ _____________
Jewelry $_____________ _____________ _____________
Life Insurance $_____________ _____________ _____________
(cash value)
Collectibles $_____________ _____________ _____________
Bank accounts
Checking $_____________ _____________ _____________
Savings $_____________ _____________ _____________
Other Assets
______________ $_____________ _____________ _____________
TOTAL ASSETS $_ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
5. A. (Indicate with (*) all which are estimates
rather than actual figures than actual figures
Taken from records or personal knowledge).