Illinois > Local County > Winnebago > Divorce
Financial Affidavit Appendix O - Illinois
| Financial Affidavit Form. This is a Illinois form and can be used in Divorce Winnebago Local County . |
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STATE OF ILLINOIS IN THE CIRCUIT COURT OF THE 17TH JUDICIAL CIRCUIT COUNTY OF WINNEBAGO IN RE THE MARRIAGE OF Plaintiff, and Defendant. FINANCIAL AFFIDAVIT INSTRUCTIONS [1] All questions require a written response. If you do not have the information requested or do not know the answer to a particular question, indicate that as your answer. [2] Use additional sheets if necessary @ Case No. Plaintiff/Defendant, being duly sworn states that the following is an , of his/her income from all sources, a statement accurate statement as of of monthly living expenses and debts and a statement of health insurance coverage. Name: Address: Date of Marriage Date of Separation Dependent Children of this Marriage: d.o.b. d.o.b. d.o.b. d.o.b. Current Employer Self-employment Other employment residing with residing with residing with residing with Address: Address Address Telephone Number Date of Birth Date of Dissolution of Marriage (if applicable) G Check Tif unemployed A-15 APPENDIX O 04/03 American LegalNet, Inc. www.FormsWorkflow.com APPENDIX O - Continued Number of paychecks per year (Please check T) Number of exemptions claimed Number of dependents Gross income from all sources last year: Gross income from all sources this year through (Year) G 12 G 24 G 26 G 52 G Other Withholding Status GM GS $ Gross Monthly Income (Compute as 4.33 if paid weekly or 2.17 if paid bi-weekly) Salary/wages/base Pay Overtime/commission Bonus Draw Pension and Retirement Benefits Annuity Interest/dividend Income Trust Income Social Security Payments Unemployment Benefits Disability Payments / Workers Compensation Public Aid / Food Stamps Rental Income Business Income Partnership Income Royalty Income Fellowship / Stipends Other Income (specify) Total Gross Monthly Income: $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ A-15.1 APPENDIX O -2- 4/03 American LegalNet, Inc. www.FormsWorkflow.com APPENDIX O - Continued Additional Cash Flow (Monthly) Maintenance received (Payments received from prior Judgment or support orders in other actions); Child support received (Payments received pursuant to Court order or voluntarily in this or other actions) Total Additional Cash Flow $ $ $ TOTAL MONTHLY GROSS INCOME FROM ALL SOURCES $ Statutory Monthly Deductions Federal Tax (based on State Tax (based on withholding status) withholding status) $ $ $ $ $ $ $ $ $ Other (specify) TOTAL REQUIRED DEDUCTIONS FROM MONTHLY INCOME MONTHLY INCOME FICA (or Social Security equivalent) Medicare Tax Mandatory Retirement Contributions required by law or as condition of employment Union Dues (Name of Union: Health/Hospitalization Premiums Prior Obligation(s) of Support actually paid pursuant to Court Order ) $ $ $ A-15.2 APPENDIX O -3- 04/03 American LegalNet, Inc. www.FormsWorkflow.com APPENDIX O - Continued STATEMENT OF MONTHLY LIVING EXPENSES as of (Do not duplicate; list only under one category) 1. Household a. Mortgage or Rent (specify) b. Home Equity Loan / Second Mortgage c. Real Estate Taxes, Assessments d. Homeowners or Renters Insurance e. Heat /Fuel f. Electricity $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ SUBTOTAL HOUSEHOLD EXPENSES $ g.. Telephone (include long distance) h. Cell Phone / Pager i. j. Cablevision Water and Sewer k. Computer l. Refuse Removal m. Laundry / Dry Cleaning n. Maid / Cleaning Service o. Furniture and Appliance Repair/Replacement p. Lawn and Garden / Snow Removal q. Food (groceries, household supplies, etc.) r. Restaurant Meals Other (specify) A.15.3 APPENDIX O -4- 04/03 American LegalNet, Inc. www.FormsWorkflow.com APPENDIX O - Continued 2. Transportation a. Gasoline b. Repairs c. Insurance / License / City Stickers d. Alternative Transportation e. Other (specify) SUBTOTAL TRANSPORTATION EXPENSES: (Number of vehicles ) $ $ $ $ $ $ 3. Personal a. Clothing b. Grooming c Medical (after insurance proceeds): (1) (2) (3) (4) (5) (6) Doctor Dentist Optical Medication Counseling Other $ $ $ $ $ $ $ $ d. Insurance: (1) (2) (3) Life Insurance Premiums Medical/Hospitalization Insurance Premiums (Not withheld from wages) Dental/Optical Insurance Premiums (Not withheld from wages) $ $ $ $ $ $ $ SUBTOTAL PERSONAL EXPENSES: e. Other (specify) $ A-15.4 APPENDIX O -5- 04/03 American LegalNet, Inc. www.FormsWorkflow.com APPENDIX O - Continued 4. Miscellaneous a. Clubs/Social Obligations/Entertainment b. Newspapers, Magazines, Books c. Gifts d. Donations, Church or Religious Affiliation e. Vacations f. Tax-deferred Contributions $ $ $ $ $ $ $ $ g. Other (specify) $ $ $ SUBTOTAL MISCELLANEOUS EXPENSES: $ ) $ $ 5. Children's Separate Expenses: (Identify special needs a. Clothing b. Grooming c. Education: (1) (2) (3) (4) (5) Tuition Books / Fees Lunches Transportation Activities $ $ $ $ $ d. Medical (after insurance proceeds): (1) A-15.5 Doctor APPENDIX O -6$ 04/03 American LegalNet, Inc. www.FormsWorkflow.com APPENDIX O - Continued (2) (3) (4) (5) Dentist Optical Medication Counseling $ $ $ $ $ $ $ $ $ $ $ $ $ $ e. Allowance f. Child Care/Before and After School Care g. Sitters h. Lessons and Supplies i. j. Clubs / Summer Camps Vacation k. Entertainment l. Other (Specify) SUBTOTAL CHILDREN'S EXPENSES: TOTAL MONTHLY LIVING EXPENSES STATEMENT OF DEBTS AND LIABILITIES CREDITOR PURPOSE BALANCE DUE MONTHLY PMT. TOTAL MONTHLY DEBT PAYMENT A-15-6 APPENDIX O -704/03 American LegalNet, Inc. www.FormsWorkflow.com APPENDIX O - Continued STATEMENT OF HEALTH INSURANCE COVERAGE Currently effective health insurance coverage: G Yes Name of insured Name of insurance carrier: Type of insurance: Deductible: Persons covered: Type of policy: Provided by: Monthly cost: RECAP MONTHLY INCOME TOTAL MONTHLY LIVING EXPENSES DIFFERENCE BETWEEN NET INCOME AND EXPENSES LESS MONTHLY DEBT PAYMENT INCOME AVAILABLE PER MONTH $ $ $ $ $ G Medical G Per Individual G Self G HMO G Employer G Paid by Employer G Spouse G PPO G Private Policy G Dental Policy or Group No. G Optical Per Family G Dependents G Standard Indemnity (i.e. 80/20) G Other Group $ for myself G No G Paid by Employee: for dependents $ Signature of Party: G Plaintiff G Defendant Type or Print Name VERIFICATION BY CERTIFICATION I certify that all of the corroborating documents to this Financial Affidavit in my possession, or that I can obtain upon reasonable effort as of this date, have been provided to the opposing party. UNDER PENALTIES of perjury as provided by law pursuant to Section 1-109 of the Code of Civil Procedure, I certify that the statements set forth in this instrument are true and correc
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