Illinois > Local County > Peoria > Civil
Financial Affidavit - Illinois
| Financial Affidavit Form. This is a Illinois form and can be used in Civil Peoria Local County . |
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A ppen d ix A t Rule 9 .2 (c ) o IN THE CIRCUIT COURT OF THE TENTH JUDICIAL CIRCUIT COUNTY, ILLINOIS IN RE THE MARRIAGE OF ) ) ) ) ) ) ) ) Plaintiff, V. Case No.: Defendant. FINANCIAL AFFIDAVIT OF 1. Marital History A. My Name: Employer: Job Title: B. Name of Opposing Party: Employer. . Job Title: C. Date parties married: D. Date parties separated: E. Date final divorce decree entered: F. Names and Current Ages of Children: Date of Birth Year in School Age: D/O/B: Education: Soc.Sec.No.: Age: D/O/B: Education: Soc.Sec.No.: Name Age Name Age Date of Birth Year in School G. H. With whom do your children live? Date and amount of last support order: 1. $ per for maintenance entered on 2. $ per for maintenance entered on (A) $ $ $ $ 2. Schedules/Summaries Schedule A: My Gross Monthly Earned Income (from Page 2): My Net Monthly Earned Income (from page 2): My Other Monthly Income (from page 2): Schedule B: Total Of All My Monthly Expenses (from page 6): (# of people in your household _____) Schedule C: Total Marital Assets (from page 7): Schedule D: Total Marital Debts (from page 8): Schedule E: Total My Non-Marital Assets (from page 9): Total My Non-Marital Debts (from page 9): 3. Do you expect your income to change significantly in the next 6 months? Why? (B) (C) $ (D) $ (E) $ $ Yes No American LegalNet, Inc. www.USCourtForms.com S C HE DULE A MONTHLY INCOME AND DEDUCTIONS (Attach recent pay stub to this Affidavit) A. STATEMENT OF MY MONTHLY INCOME AND DEDUCTIONS: 1. . * Gross Earned Income Per Month from: (state name of employer) (a) Salary/Wages (b) Other earned income (second job) (a) $ (b) $ * If you are paid weekly, multiply income by 4.33 to get monthly amount or If you are paid every 2 weeks, multiply income by 2.17 to get monthly amount or If you are paid twice a month, multiply income by 2 to get monthly amount (put on front page) 2. * * Deductions Per Month: (a) (b) (c) (d) (e) (f) (g) (h) (i) (j) Federal Taxes State Taxes Social Security Medicare Mandatory Pension Union Dues Health Insurance Individual Health Insurance Dependent Court Ordered Child Support Other (Filing status: Single/Married (circle one) (No. of exemptions claimed: ) (a) (b) (c) (d) (e) (f) (g) (h) (i) (j) $ $ $ $ $ $ $ $ $ $ ** If you are paid weekly, multiply income by 4.33 to get monthly amount or If you are paid every 2 weeks, multiply income by 2.17 to get monthly amount or If you are paid twice a month, multiply income by 2 to get monthly amount TOTAL DEDUCTIONS: $ MY NET MONTHLY EARNED INCOME: (put on front page) (subtract Total Deductions from Gross above) B. MY OTHER MONTHLY INCOME: (a) (b) (c) (d) (e) (f) (g) Dividends: Interest: Child Support: Maintenance: Social Security (for myself and dependents): Pension Benefits: Other (specify) (a) (b) (c) (d) (e) (f) (g) $ $ $ $ $ $ $ MY OTHER MONTHLY INCOME: (put on front page) C. Do other adults living In your household have Income? Yes No American LegalNet, Inc. www.USCourtForms.com S C HE DULE B MONTHLY EXPENSES 1. State Total Number of People in your Household: List names of people in your household (exclude yourself): Names Age Relationship 2. Monthly Housing Expenses: (Show 1/12th of Annual Total for Expenses Not Paid Monthly) A. B. C. D. E. F. G. H. I. J. K. L. M. N. O. P. Q. R. Rent/Mortgage payment (circle one) Home equity loan Property taxes Condo maintenance fee Homeowner's or Renter's insurance (circle one) Gas/Electric Water Sewer Garbage collection Telephone Cable television Household help House repairs Groceries. Household supplies Laundry & dry cleaning Lawn care and snow removal Other (A) (B) (C) (D) (E) (F) (G) (H) (I) (J) (K) (L) (M) (N) (O) (P) (Q) (R) $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ TOTAL MONTHLY HOUSING EXPENSES: 3. Monthly Medical Expenses (not paid by Insurance): (Show 1/12th of Annual Total for Expenses Not Paid Monthly) A. B. C. D. E. Self Child/Children Dentist: Self Child/Children Orthodontist: Self Child/Children Medicines/Prescription Drugs: Other (specify) Doctors: $ $ (B) $ $ (C) $ $ (D) $ (E) $ $ (A) TOTAL MONTHLY MEDICAL EXPENSES: American LegalNet, Inc. www.USCourtForms.com 4. Monthly Auto Expenses: (State number of car ______) (Show 1/12th of Annual Total for Expenses Not Paid Monthly) A. B. C. D. E. F. G. Monthly payment (Car.No. 1) Monthly payment (Car.No. 2) Gasoline and Oil Maintenance and repairs Registration Insurance Parking (A) (B) (C) (D) (E) (F) (G) $ $ $ $ $ $ $ $ TOTAL MONTHLY AUTO EXPENSES: 5. Monthly Child Care Expenses (State number of children: _____) (Show 1/12th of Annual Total for Expenses Not Paid Monthly) A. B. C. D. E. F. G. H. I. J. K. L. M. N. O. Clothing/Shoes Daycare Eyeglasses/contacts Hairdresser/Barber Grooming/Cosmetics Lunch money Allowances Gifts and Presents (Birthdays/Christmas) Tuiltion/books/fees/school supplies Transportation (school bus fees) Lessons/tutoring Recreation, sports and hobby expenses Babysitter Summer camp Other (specify) (A) (B) (C) (D) (E) (F) (G) (H) (I) (J) (K) (L) (M) (N) (O) $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ TOTAL MONTHLY CHILD CARE EXPENSES: 6. My Monthly Personal Expenses: (Show 1/12th of Annual Total for Expenses Not Paid Monthly) A. B. C. D. E. F. G. H. I. J. K. L. M. N. O. P. Q. Clothing/Shoes Business/Work Uniforms Eyeglasses/Contacts Hairdresser/Barber . Grooming/Cosmetics Lunch money Professional Union Dues not withheld from wages Education expenses Books, magazines, newspapers, etc. Recreation, sports and hobby expenses Religious/Charitable contributions Vacations Social/Club dues and expenses Gifts and presents (not for your children) Pet expenses Tobacco/Alcohol Other (specify) (A) (B) (C) (D) (E) (F) (G) (H) (I) (J) (K) (L) (M) (N) (O) (P) (Q) $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ American LegalNet, Inc. www.USCourtForms.com TOTAL MONTHLY PERSONAL EXPENSES: 7. Monthly Insurance Premiums Not Withheld From Wages: (Show 1/12th of Annual Total for Expenses Not Paid Monthly) A. B. C. D. Life insurance not withheld from wages: Health insurance not withheld from wages: Disability insurance not withheld from wages: Other (specify) (A) $ (B) $ (C) $ (D) $ $ TOTAL MONTHLY INSURANCE EXPENSES: 8. Debts and Obligations Requiring Regular Monthly Payments Not Listed in Paragraphs 2-7 above (such as credit cards, credit accounts, consumer loans, personal loans, etc.) (Show 1/12th of Annual Total for Expenses Not Paid Monthly) Name of Creditor A. B. C. D. E. F. G. H. I. J. K. L. M. N. O. Reason for Debt Balance Owed Monthly Payment TOTAL OF PARAGRAPH 8 MONTHL
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