COURT COUNTY OFDR-10 (3/01)IN THE COMMON PLEAS COURT OF MONTGOMERY COUNTY, OHIO DIVISION OF DOMESTIC RELATIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.CASE NO.PLAINTIFF/PETITIONER (1) Address:JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)SETS NO. JUDGE:CROSS / KING-vs-/ -and-AFFIDAVIT OF FINANCIAL DISCLOSURE (MONT. D. R. RULE 4.10). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .DEFENDANT/PETITIONER (2)Address:THE PEOPLE OF THE STATE OF NEW YORK TOSTATE OF OHIO, SS:GREETINGS:Now 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 support when applicable. I.WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,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 roomTEMPORARY ORDERS/OTHER ACTIVE CASES: I do not request a temporary order. I request a temporary order for custody, child support, and/or spousal support. A Domestic Violence Order under Case No. currently is in effect. A URESA or Juvenile Court Case under Case No. currently is in effect. A Bankruptcy action under Case No. was filed . DATE OF SEPARATION (NEW CASES) II.MINOR AND/OR DEPENDENT CHILDREN ONLY OF THIS MARRIAGE: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,DOB:Residing with DOB:Residingwith DOB:Residingwith DOB:Residingwith EMPLOYMENT OR SCHOOL RELATED CHILD CARE EXPENSES FOR THESE CHILDREN: $per year(Attorney must sign above and type name below)III.INCOMEA.GROSS YEARLY INCOME FROM EMPLOYMENTAttorney(s) forPLAINTIFF/PETITIONER (1)DEFENDANT/PETITIONER (2) YES NO................................................. Employed? .....................................................YES NO $$ or Gross Receipts if Self-Employed(Actual or Estimate)........Base Yearly Wages........(Actual or Estimate)$......Office and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:..........................Employer ......................... .....................Payroll Address .................... ..................... City, State, Zip.....................Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.com1COURT COUNTY OFB.OTHERINCOMEof otherSection E.). . . . . . . . .YEARLY. . . . . . . . . . . . . . .(Please. . . . . .list. . .all. .sources. . . . . . . . . . . . .income. . . . . .in:::::::Index No.PLAINTIFF/PETITIONER (1)DEFENDANT/PETITIONER (2)Calendar No.$Interest/Dividend Income$JUDICIAL SUBPOENAPlaintiff(s)$Unemployment Compensation$-against-Workers' Compensation, Social Security or Other Disability Benefits$$Social Security & Pension Income$$$Gross Self-Employment Income$Defendant(s)Ordinary & Necessary Business Expenses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$$C.ANNUAL INCOME, OVERTIME, COMMISSION AND BONUSES EARNED: Three Year History -Year 3 Is Most Recent Year]THE PEOPLE OF THE STATE[PastOF NEW YORK TOOvertime, Commission, BonusesOvertime, Commission, Bonuses19 Year 1 $19 Year 1 $19 Year 2 $19 Year 2 $20 Year 3 $20 Year 3 $GREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the HonorableTOTAL INCOME FROM ALL SOURCES, (A, plus B, plus Average of C),located at County ofPLAINTIFF $ DEFENDANT $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 roomD.OTHER INFORMATION CONCERNING CHILDREN: PLAINTIFF/PETITIONER (1)DEFENDANT/PETITIONER (2)Court Ordered Child Support Payable for Other Child(ren) Who Are Not of this MarriageYour 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 $50 and all damages sustained as a result of your failure to comply.$per yearper year$Court Ordered Spousal Support Payable to a Spouse(s)$per yearper year$, one of the Justices of theNumber of Other Minor Child(ren) Living With You (not children of this marriage or step-children)Court in Witness, Honorableday of, 20 County,Child Support You Receive for the Minor Child(ren) You Indicated on Line Above(Attorney must sign above and type name below)$per yearper year$E.OTHER ASSETS AND LUMP SUM INCOMEAttorney(s) for1.Describe income sources listed in Section B (i.e., retirement/pension benefits, disability income, interests or dividend income, rentals, annuities, etc.) Attach additional pages if needed. Name & AddressIncome or Benefits of SourceIdentifying Description(Account No., Claim No., Etc.)Office and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:2American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.2.List any lump sum income (bonus, gifts, inheritance, etc.) in excess of $500, expected to be received within the next six months, not otherwise listed in this affidavit. Attach additional pages if needed.Calendar No.SourceValue$JUDICIAL SUBPOENAPlaintiff(s)-against-3.List all funds on deposit in any and all accounts in any bank, savings & loan, credit union, regulated investment company, mutual fund or other financial institution. Account includes any of the following: checking, certificate of deposit ("CD"), investment, savings, individual retirement account ("IRA"), stock option, etc. Attach additional pages if needed.Name & Address ofName(s) Financial InstitutionAccount Numberon AccountBalanceDefendant(s). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .THE PEOPLE OF THE
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