Illinois > Local County > Lake > Family Law
Financial Affidavit 11.02 171-12 FD33 - Illinois
| Financial Affidavit 11.02 Form. This is a Illinois form and can be used in Family Law Lake Local County . |
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IN TH E CIR CU I T COU R T OF TH E NI NETEENTH JUDIC I AL CI RCUIT LAKE CO UNTY , I L LINOIS IN RE: The U Marriage of: U Custody of: U S upport o f: ) ) ______________________________________ ) Petitioner ) and ) No. ______ __________ ) ______________________________________ ) Resp ondent ) FINANCIAL AFFIDAVIT 11.02 Affiant, ___ ________________________________________, having been d uly sworn, upon oath, states that the informati on contai ned her ein is true a nd correct as of , 20 Na me : Tele phone No : ( ) Ad dress : Petition e r Dat e of Bir t h : ______ ______ (mmddyyyy) Res pon de nt Da te of Birth : ___ _ _______ (mmddyyyy) Dat e of M a rriage : ___ ________________ D a te of Dis s o lut io n of Ma r r ia g e : (if applicable) (mmddyyyy) ____________ ( mmddy yyy) Minor an d/or Depen d ent Children of thi s Marri age : Dat e of Birt h Name Curre ntl y L iving Wi th ( mmddyyyy) (At t a ch add it iona l pa ge (s) as n eed ed ) Curre nt E m ployer : Addres s: Sel f Empl oyment : Addres s: Other E m ployment : Addres s: U Check if unemployed Numb er o f Paych e ck s per ye ar : (Please Check box) U 1 2 U 2 4 U 26 U 52 U Other _______ Number of Exempti o ns clai med: ________ _______ Number of Depen d en ts clai med: ________ _______ Gross Inc o me from al l sources l a st year: _ ______________________________________ Gross inc o me from al l sources t h is year t h rough ___ ____________: $ ___ ___________ Date American LegalNet, Inc. www.USCourtForms.com Page 1 of 5 171- 12 FD33 (R 12/04) <<<<<<<<<********>>>>>>>>>>>>> 2 STATEMENT OF INCOME Gross Monthly Income Sal a ry/Wages/Base Pay $ Overtime/Commission $ Bonus $ Draw $ Pension and Reti rement Benefi ts $ Annuity $ Interest inc ome $ Dividend income $ Trust income $ Social Secu rity $ Unemployment bene fits $ Disability payment $ Workers Compensation $ Public Aid/Food Stamps $ Investment income $ Rental income $ Business i ncome (i ncluding non-ta xable distributions) $ Partnership income $ Royal t y income $ Fellowship/stipends $ Other income (specify): _______ _________________ $ TOT A L GROSS MONT HLY INCO ME: $ $ Additional Cash Flow (Monthly) Sp ous a l supp ort r e ceiv ed (s pecif y ) $ U Purs uant to a prior judgment or order in another ca se $ U Purs uant to a prior judgment or order in this case $ U Voluntarily paid in this case $ Child Support r e ceived (s pecify) $ U Purs uant to a prior judgment or order in another ca se $ U Purs uant to a prior judgment or order in this case $ U Voluntarily paid in this case $ To ta l ad diti o n a l ca sh f low : $ $ Required Monthly Deductions Federal Tax (based on ______ ____ exemptions) $ State Tax (based on ________ __ exemptions) $ FICA (or Soci al Securi ty equi va le nt) $ Medicare Tax $ Man dat ory reti rement co ntributions required by law o r $ as condit ion of employment Union Dues (Name of Union: _ __________________) $ Health/hospit alizat ion Premiu ms $ Prior obligat ion( s) of su pport actually paid pursu ant t o $ Court order Other ( specify) $ T OTA L R EQU IR E D DE DU CTIO NS FR OM I N COM E: $ $ NET MONTHLY INCOME: $ $ American LegalNet, Inc. www.USCourtForms.com Page 2 of 5 171- 12 FD33 (R 12/04) <<<<<<<<<********>>>>>>>>>>>>> 3STATEMENT OF MONTHLY LIVING EXPEN S ES 1. House h old a. Mortga ge or rent (sp ecify): $ b. Home equi ty loan pa yment $ c. Real estate taxes, as sessments $ d. Homeowners or renters insurance $ e. Heat/fuel $ f. Elect ricity $ g. Telephone (include long distanc e) $ h. Water an d Sewer $ i. Refuse re moval $ j. Laundry/dry cleaning $ k. Maid/clea ning serv ice $ l. Furnit ure an d appliance repair/ replacemen t $ m. Lawn a nd garden care/snow re moval $ n. Food (groceries, household supplies, etc.) $ o. Liquor, b eer, wi ne, e t c. $ p. Other (sp ecify): $ SUB TOTAL HOUSE H OL D EXPEN S ES: $ $ 2. Transportation a. Fuel $ b. Repairs/maintenanc e $ c. Insuranc e/license/city stickers $ d. Pa yment s/replacement $ e. Other (sp ecify): $ SUB T OTAL TR ANSPO R TA TION EXPENS ES : $ $ 3. Personal a. Cl othing $ b. Grooming $ c. Medical (af t er insu ran ce proceeds/reimbursement) (1) Doctor $ (2) Denti st $ (3) Opti cal $ (4) Medi cation $ d. Insuranc e (1) Li fe Term/Whol e (specify ) $ (2 ) Medical/Hospitalizat ion $ (3 ) Dental/Opt ical $ e. Other (sp ecify) $ SUBTOTAL PERSONAL EX PENSES: $ $ 4. Miscellaneous: a. Cl ubs/social oblig at ions/entertai nment $ b. Newspap e rs, magazines, books $ c. Gifts $ d. Donations, c hurc h or relig ious affi liations $ e. Vacations $ f. Other (s pe cify) $ SUB T OTAL MISCELLA NEOU S E XPENSES $ $ American LegalNet, Inc. www.USCourtForms.com Page 3 of 5 171-12 FD33 (R12/04) <<<<<<<<<********>>>>>>>>>>>>> 45. Dependent children: Na me : Age : Nam e: Ag e: Na me : Age : Nam e: Ag e: Na me : Age : Nam e: Ag e: a. Cl othing $ b. Grooming $ c. Educa t ion (1) T uit ion $ (2) Books/ Fees $ (3) L unches $ (4) Tra nsportati on $ (5) Medi cation $ d. Me dical (af ter insu ran ce proceeds/reimbursement) (1) Doctor $ (2) Denti st $ (3) Opti cal $ (4) Medi cation $ e. Allowance $ f. Child care/After-sc hool care $ g. Si tters $ h. Lesson a nd s upplies $ i. Clubs/Summer Camps $ j. Vacation $ k. En tertai nment $ l. Other (sp e cify) $ SUB TOTAL CHILD RE NS EXPEN S ES: $ $ TOTAL MONTHLY LIVING EX PENSES: $ $ STATEMENT OF LIABILITIES CREDITORS NAME PAYMENT FOR BALANCE DUE MONTHLY PAYMENT $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ TOTAL LIABILITIES $ TOTAL MO NTHLY DE BT SE RVICE $ ( A ttac h addi tio n al page( s ) as ne ed ed ) American LegalNet, Inc. www.USCourtForms.com Page 4 of 5 171- 12 FD33 (R 12/04) <<<<<<<<<********>>>>>>>>>>>>> 5STATEMENT OF ASSETS CASH or CASH EQ UIVALENTS: 1. Savi ngs or interest-beari ng accounts $ 2. Checking Accounts $ 3. Certificates of Deposit $ 4. Mo ney Market Accounts $ 5. Ca sh $ 6. Ot her (sp e cify): $ TOTAL CASH O R CASH EQ UIVALENTS $ $ INVESTMENT ACCOUNTS and SECURITIES: 1. Stocks $ 2. Bonds $ 3. Tax exe mpt securities $ 4. Ot her (sp e cify): $ TOT A L INV E STMEN T ACC OUN TS AND SEC URITIE S $ $ STATEMENT OF HEALTH INSURANCE COVERAGE Current ly effect ive healt h insurance coverage? U Yes U No Name of insurance carrier: ______ _______________________________________________________ Policy of Group No.: __ ________________________ Type of ins urance: U Medical U Dental U Optical Deductible: Per indivi dual: $________ Per family: $________ Persons co vered: U Sel f U S pouse U Depe ndents Type of policy: U HMO U PPO U Full inde
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