Ohio > County (Court Of Common Pleas) > Clermont > Domestic Relations
Affidavit Of Income And Expenses DR-501 - Ohio
| Affidavit Of Income And Expenses Form. This is a Ohio form and can be used in Domestic Relations Clermont County (Court Of Common Pleas) . |
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_________________________ Plaintiff/Petitioner v./and COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS CLERMONT COUNTY, OHIO Case No. ___________________________ Judge __________________________ Magistrate ________________________ _________________________ Defendant/Petitioner Instructions: This affidavit is used to make complete disclosure of income, expenses and money owed. It is used to determine child and spousal support amounts. Do not leave any category blank. Write "none" where appropriate. If you do not know exact figures for any item, give your best estimate, and put "EST". This affidavit may be used by the Court in issuing temporary support orders under Rule 75 of the Ohio Rules of Civil Procedure. However, this affidavit may NOT be considered as evidence at any future hearing unless offered and admitted under the Ohio Rules of Evidence. You must provide verification of your income and the income of the opposing party or state the reason(s) why you cannot provide verification. If verification of income(s) is not provided, a support order may not issue. AFFIDAVIT OF INCOME AND EXPENSES Affidavit of ______________________________ (Print Your Name) Date of marriage _____________ Date of separation _____________ SECTION I INCOME Husband Employed Employer Payroll address Payroll city, state, zip Scheduled paychecks per year Yes No Yes Wife No 12 24 26 52 12 24 26 52 A. YEARLY INCOME, OVERTIME, COMMISSIONS AND BONUSES FOR PAST THREE YEARS Husband Base yearly income $ $ $ $ $ $ 3 years ago 2 years ago Last year 3 years ago 2 years ago Last year 20____ 20____ 20____ 20____ 20____ 20____ $ $ $ $ $ $ Wife Yearly overtime, commissions and/or bonuses Page 1 of 8 American LegalNet, Inc. www.FormsWorkFlow.com B. COMPUTATION OF CURRENT INCOME Husband Base yearly income Average yearly overtime, commissions and/or bonuses over last 3 years (from part A) Unemployment compensation Disability benefits calculate yearly amount Workers' Compensation Social Security Other:________________________ $ Wife $ $ $ Retirement benefits calculate yearly amount Social Security Other:_______________________ $ Spousal support received Interest and dividend income (source) per year _______________________________ _______________________________ $ $ Other income (type and source) per year _______________________________ _______________________________ $ TOTAL YEARLY INCOME $ Supplemental Security Income per year (SSI) or public assistance Court-ordered child support that you receive for minor and/or dependent child(ren) not of the marriage or relationship $ $ Page 2 of 8 American LegalNet, Inc. www.FormsWorkFlow.com SECTION II CHILDREN AND HOUSEHOLD RESIDENTS Minor and/or dependent child(ren) who are adopted or born of this marriage or relationship: Name Date of birth Living with In addition to the above children there is/are in your household: ________ adult(s) ________ other minor and/or dependent child(ren). SECTION III EXPENSES List monthly expenses below for your present household. A.MONTHLY HOUSING EXPENSES Rent or first mortgage (including taxes and insurance) Real estate taxes (if not included above) Real estate/homeowner's insurance (if not included above) Second mortgage/equity line of credit Utilities o Electric o Gas, fuel oil, propane o Water and sewer o Telephone o Trash collection o Cable/satellite television Cleaning, maintenance, repair Lawn service, snow removal Other:____________________________________________ Other:____________________________________________ TOTAL MONTHLY: $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Page 3 of 8 American LegalNet, Inc. www.FormsWorkFlow.com B. OTHER MONTHLY LIVING EXPENSES Food o Groceries (including food, paper, cleaning products, toiletries, other) o Restaurant Transportation o Vehicle loans, leases o Vehicle maintenance (oil, repair, license) o Gasoline o Parking, public transportation Clothing o o Clothes (other than children's) Dry cleaning, laundry $ $ $ $ $ $ $ $ Personal grooming o o Cell phone Internet (if not included elsewhere Other ______________________________________________ TOTAL MONTHLY Hair, nail care Other _______________________________________ $ $ $ $ $ $ C. MONTHLY CHILD-RELATED EXPENSES (for children of the marriage or relationship) Work/education-related child care Other child care Unusual parenting time Travel Special and unusual needs of child(ren) (not included elsewhere) Clothing School supplies Child(ren)'s allowances Extracurricular activities, lessons School lunches (cost for school year, divided by 12 months) Other ______________________________________________ TOTAL MONTHLY $ $ $ $ $ $ $ $ $ $ $ Page 4 of 8 American LegalNet, Inc. www.FormsWorkFlow.com D. INSURANCE PREMIUMS Life Auto Health Disability Renters/personal property (if not included in Part A above) Other _____________________________________________ TOTAL MONTHLY $ $ $ $ $ $ $ E. MONTHLY EDUCATION EXPENSES Tuition o o Self Child(ren) $ $ $ $ Books, fees, other College loan repayment Other ______________________________________________ ______________________________________________ TOTAL MONTHLY $ $ F. MONTHLY HEALTH CARE EXPENSES (not covered by insurance) Physicians Dentists Optometrists/opticians Prescriptions Other _______________________________________________ _______________________________________________ TOTAL MONTHLY $ $ $ $ $ $ G. MISCELLANEOUS MONTHLY EXPENSES Extraordinary obligations for other minor/handicapped child(ren) (not stepchildren) Child support for children who were not born of this marriage or relationship and were not adopted of this marriage Spousal support paid to former spouse(s) Subscriptions, books Entertainment $ $ $ $ $ Page 5 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Charitable contributions Memberships (associations, clubs) Travel, vacations Pets Gifts Bankruptcy payments Attorney fees Required deductions from wages (excluding taxes, Social Security and Medicare) (type) ___________________________________ Additional taxes paid (not deducted from wages)(type) ____________________________________________________ Other _______________________________________________ _______________________________________________ TOTAL MONTHLY $ $ $ $ $ $ $ $ $ $ $ H. MONTHLY INSTALLMENT PAYMENTS (Do not repeat expenses already listed.) Examples: car, credit card, rent-to-own, cash advance payments To whom paid Purpose $ $ $ $ $ $ $ $ $ $ $ Balance due $ $ $ $ $ $ $ $ $ $ $ TOTAL MONTHLY S Monthly payment GRAND TOTAL MON
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