Kansas > Local District Court > 10th Judicial District (Johnson County) > Divorce > With Children
Domestic Relations Affidavit - Kansas
| Domestic Relations Affidavit Form. This is a Kansas form and can be used in With Children Divorce 10th Judicial District (Johnson County) Local District Court . |
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Domestic Relations Affidavit IN THE JUDICIAL DISTRICT COUNTY, KANSAS IN THE MATTER OF ) ) ) ) ) and ) Case No. ) ) ) ) DOMESTIC RELATIONS AFFIDAVIT OF ( name) 1. Mothers Residence Mothers Date of Birth Social Security Number Home Telephone 2. Fathers Residence Fathers Date of Birth Social Security Number Home Telephone 3. Date of Marriage: 4. Number of Marriages: M other F ather 5. Number of children of the relationship: 6. Names, Social Security Numbers, birthdates, and ages of minor children of the relationship: Name Social Security No. Date of Birth Age Custodian <<<<<<<<<********>>>>>>>>>>>>> 27. Names, Social Security Numbers, and ages of minor children of previous relationships and facts as to custody and support payments paid or received, if any. Social Support Paid Name Security No. Age Custodian Payment or Recd $ $ $ $ 8. Mother is employed by Father is employed by (Name and address of employer) with monthly income as follows: A. Wage Earner Mother Father 1. Gross Income $ $ 2. Other Income $ $ 3. Subtotal Gross Income $ $ 4. Federal Withholding $ $ (Claiming _____ exemptions) 5. Federal Income Tax $ $ 6 . OASDHI $ $ 7. Kansas Withholding $ $ 8. Subtotal Deductions $ $ 9 . Net Income $ $ B. Self-Employed Mother Father 1. Gross Income from self-employment $ $ 2. Other Income $ $ 3. Subtotal Gross Income $ $ 4. Reasonable Business Expenses $ $ (Itemize on attached exhibit) 5. Self-Employment Tax $ $ 6. Estimated Tax Payments $ $ (Claim _____ exemptions) 7. Federal Income Tax $ $ 8. Kansas Withholding $ $ 9. Subtotal Deductions $ $ 10. Net Income $ $ (Line B.3. minus Line B.9.) Pay period: M other Father <<<<<<<<<********>>>>>>>>>>>>> 39. The liquid assets of the parties are: Joint or Individual Item Amount (Specify) A. Checking Accounts: $ $ B. Savings Accounts: $ $ C. Cash Mother $ Father $ D. Other $ $ 10. The monthly expenses of each party are: (Please indicate with an asterisk all figures which are estimates rather than actual figures taken from records.) A . M other F athe r Item (Actual or Estimated) (Actual or Estimated) 1. Rent (if applicable)* $ $ 2. Food $ $ 3. Utilities: Trash Service $ $ Newspaper $ $ Telephone $ $ Gas $ $ Water $ $ Lights $ $ Other $ $ 4. Insurance: Life $ $ Health $ $ Car $ $ House/Rental $ $ Other $ $ 5. Medical and dental $ $ 6. Prescriptions drugs $ $ 7. Child care (work-related) $ $ 8. Child care (non-work-related) $ $ 9. Clothing $ $ 10. School expenses $ $ 11. Hair cuts and beauty $ $ 12. Car repair $ $ 13. Gas and oil $ $ 14. Personal property tax $ $ <<<<<<<<<********>>>>>>>>>>>>> 4 M other F athe r Item (Actual or Estimated) (Actual or Estimated) 15. Miscellaneous (Specify) $ $ $ $ $ $ $ $ 16. Debt Payments (Specify) $ $ $ $ $ $ $ $ T otal $ $ *Show house payments, mortgage payments, etc., in Section 10.B. B. Monthly payments to banks, loan companies or on credit accounts: (Indicate actual or estimated, use asterisk for secured.) DO NOT LIST ANY PAYMENTS INCLUDED IN PART 10.A ABOVE. When Amount of Date of Responsibility Creditor Incurred Payment Last Payment Balance Mother Father $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Subtotal of Payments $ $ T otal $ $ C. Total Living Expenses Mother F ather (Actual or Estimated) (Actual or Estimated) 1. Total funds available to $ $ Mother and Father ( from No. 8) 2. Total needed $ $ (from No. 10.A and B) 3. Net Balance $ $ 4. Projected child support $ $ <<<<<<<<<********>>>>>>>>>>>>> 5 D. Payments or contributions received, or paid, for support of others. Specify source and amount. Source Mother Father (+/-) $ $ (+/-) $ $ (+/-) $ $ (+/-) $ $ 11. How much does the party who provides health care pay for family coverage? $ per . How much does it cost the provider to furnish health insurance only on the provider? $ per . FURNISH THE FOLLOWING INFORMATION IF APPLICABLE. 12. Income and financial resources of children. Income/Resources Amount $ $ $ $ 13. Child support adjustments requested. M other F ather Long Distance Visitation Costs $ $ $ $ V isitation Adjustments $ $ Income Tax Considerations $ $ Special Needs $ $ Agreement Past Minority $ $ Overall Financial Condition $ $ 14. All other personal property including retirement benefits (including but not limited to qualified plans such as profit-sharing, pension, IRA, 401[k], or other savings-type employee benefits, nonqualified plans, and deferred income plans), and ownership thereof (joint or individual), including policies of insurance, identified as to nature or description, ownership (joint or individual), and actual or estimated value. Joint or Individual Amount (Specify) $ $ $ $ <<<<<<<<<********>>>>>>>>>>>>> 6 THE FOLLOWING NEED NOT BE FURNISHED IN POST JUDGMENT PROCEDURES. 15. List real property identified as to description, ownership (joint or individual) and actual or estimated value. Property Description Ownership Actual/Estimated Value 16. Identify the property, if any, acquired by each of the parties prior to marriage or acquired during marriage by a will or inheritance. S ource of A ctual/ Property Description Ownership Ownership Estimated Value 17. List debt obligations, including maintenance, not listed in Section 10.A or 10.B above, identified as to name or names of obligor or obligors and obligees, balance due and rate at which payable; and, if secured, identify the encumbered property. Debt Balance Payment Encumbered Obligation Obligor Obligee Due Rate Property <<<<<<<<<********>>>>>>>>>>>>> 718. List health insurance coverage and the right, pursuant to ERISA 601-608, 29 U.S.C. 1161-1168 (1986), to continued coverage by the spouse who is not a member of the covered employee group. Health Insurance COBRA Continuation Yes No Unknown AFFIANT /s/ VERIFICATION State of , County of , I swear or affirm under penalty of perjury that this affidavit and attached schedules are true and complete. /s/ Subscribed and sworn this day of , 20 . / s/ Notary Public My Appointment Expires:
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