COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.IN THE COURT OF COMMON PLEASRevised 3/22/01 DIVISION OF DOMESTIC RELATIONS MAHONING COUNTY, OHIOCalendar No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s))CASE NO. ) )JUDGE BETH A. SMITH SSN:) DOB:) EMPLOYER:)) PLAINTIFF/PETITIONER) )) VS./AND. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .)AFFIDAVIT OF INCOME, EXPENSES THE PEOPLE OF THE STATE OF NEW YORK TO)AND FINANCIAL DISCLOSURE )OF ) SSN:) DOB:) EMPLOYER:)) DEFENDANT/PETITIONERGREETINGS:)WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,STATE OF OHIO, SS:located at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomNow comes , affiant herein, and having been duly cautioned and sworn, states that he/she has been advised that this Affidavit may be used for any or all of the following purposes: (1) to make complete disclosure of affiant's income, liabilities and expenses; (2) to assist in determining orders of child support or spousal support when applicable or any changes thereto; and (3) to provide for the issuance of the appropriate deduction order for support.Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply., one of the Justices of theCourt in Witness, Honorableday of, 20 County,Date of Marriage Date of Separation Date of Divorce/Dissolution Decree (If Post-Decree Case) Minor and/or Dependent Children of this Marriage: 1. DOB 4. DOB 2. DOB 5. DOB 3. DOB 6. DOB(Attorney must sign above and type name below)Attorney(s) forFATHER/HUSBANDMOTHER/WIFE EMPLOYER/PAYOREMPLOYER/PAYORName of Employer Payroll Address City, State, ZipOffice and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:1224522624125226(Circle One)Paychecks Per Year(Circle One)Mobile Tel. No.:1American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.ATTACH A COPY OF 3 RECENT PAYSTUBS AND W-2 OR FEDERAL INCOME TAX RETURN FOR LAST YEARCalendar No.SECTION I. GROSS INCOMEFATHER/HUSBANDMOTHER/WIFEJUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)Yearly Income from Employment$$Three years agoYear 3 -20 $Year 3 -20 $Two years agoYear 2 -19$Year 2 -19 $Last Calendar YearYear 1 -19$Year 1 -19 $. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .THE PEOPLE OF THE STATE OF NEW YORK TO$ Yearly Average Overtime, Commission & Bonus Income $ (Average of Past Three Years) $Unemployment benefits$$Worker's Compensation$Social Security or Other Disability Benefits $(Identify)$GREETINGS:$Retirement Benefits$WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable$Interest/Dividend Income$,located at County ofOther Income Received $o'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in room(Identify) --(inc. spousal support)$$TOTAL YEARLY INCOME$Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.ADJUSTMENTS Court Ordered Support Paid $peryearfor other child(ren)$peryearCourt Ordered Spousal Support $peryear, one of the Justices of thePaid to any Spouse$peryearCourt in Witness, Honorableday of, 20 County,Number of Other Dependent Children living with the Party (Excluding Unadopted Step Children)(Attorney must sign above and type name below)Child Support Received for Other Dependent Children $peryearIndicated Immediately Above$peryearAttorney(s) forHealth Insurance Premium Paid $peryearFamily plan cost less Individual plan cost$peryear$peryearLocal Income Taxes Paid$peryearOffice and P.O. Address$peryearSelf-Employment Tax (5.6% of AGI)$peryear$peryearOther (Union dues, etc.)$peryearTelephone No.: Facsimile No.: E-Mail Address:$peryear$ peryearWork Related Child Care ExpenseMobile Tel. No.:2American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.SECTION II. AFFIANT'S MONTHLY EXPENSESCalendar No.A. HOUSING:E. TRANSPORTATION: 1. Rent or MortgageJUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)$1. Car Loan$ 2. Taxes (only if not incl. in mortgage)$2. Car Loan/Lease$ 3. Insurance (only if not incl. in mortgage)$3. Car Insurance$ 4. Second Mortgage$4. Gas and Oil$ 5. Maintenance/Repair$ B. UTILITIES: 1. Gas$G. INSURANCE: 2. Electric$1. Life$ 3. Water & Sewer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$2. Health$ 4. Telephone$3. Disability$ 5. Trash Collection$ 6. Cable Television$H. CHILDCARE:$ 1. Work RelatedTHE PEOPLE OF THE STATE OF NEW YORK TO$ 2. Other$ C. FOOD: 1. Groceries$ 2. School Lunches$I. OTHER: 1.$ 2.$ D. MEDICAL:GREETINGS:3.$ 1. Doctor$4. $ 2. Dentist/OrthodontistWE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable$5.$ 3. Prescriptions,$6.$ 7. $ E. CLOTHING:located at County of8. $ 1. Regularo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in room$ 2. Dry Cleaning$Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.TOTAL MONTHLY EXPENSES: $SECTION III. MONTHLY INSTALLMENT PAYMENTS, one of the Justices of theCREDITOR:DEBTORREASON FOR LOANORIGINAL AMOUNT MONTHLY PAYMENT BALANCE DUECourt in Witness, Honorableday of, 20 County,(H, W, JT) 1.$ 2.$$$ 3. $
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