Affidavit Of Income {DR 602A}

DR 602A Eff. 1/1/2015 IN THE COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS BUTLER COUNTY, OHIO Case No. ___________________ _____________________________________ Plaintiff/1st Petitioner/Petitioner DOB ________________________________ Address ______________________________ ______________________________ V. _____________________________________ Defendant/2nd Petitioner/Respondent DOB ________________________ Address Affidavit of Income ______________________ (Name of Affiant) Date of Marriage __________________ Date of Separation_________________ ______________________ _____________________________ Note: This affidavit must be completed and exchanged in accordance with Local Rules of Court in every action for divorce, dissolution, legal separation, annulment and post decree motion that concerns modification of support. You will be required to provide proof of income per local rule and O.R.C. 3121. You are under a continuing legal duty to file an updated version of this form if you learn of any additional information. If more space is needed, attach additional page(s). I. Income [As defined in O.R.C. 3119.01(C)]: A. Gross Yearly Income from Employment (If not known, please estimate. Put "EST" after each estimated figure.) Husband / Father Gross Yearly Employment Income Employer Address of Employer City, State, Zip Check the number of Paychecks per year Year-to-date Gross Income Prior Year's Tax Refund Wife / Mother 12 24 26 52 12 24 26 52 Through date of Through date of American LegalNet, Inc. www.FormsWorkFlow.com Initialed Income Affidavit Page 1 B. Annual Overtime, Commissions, Bonuses (If not known, please estimate. Put "EST" after each estimated figure.) Husband / Father Year 3 is Most Recent Year 20 20 20 Year 1 Year 2 Year 3 Base Income Overtime, Commission, Bonuses 20 20 20 Year 3 is Most Recent Year Year 1 Year 2 Year 3 Wife / Mother Base Income Overtime, Commission, Bonuses Y-T-D This Year Through:_____ Y-T-D This Year Through: _______ C. Gross Self-Employment Income (If not known, please estimate. Put "EST" after each estimated figure.) Use Gross Annual Figures for Most Recent Full Year. See O.R.C. 3119.01(C) Husband / Father Wife / Mother Business Receipts Ordinary & Necessary Business Expenses Net Business Income D. Other Income All other income, actual or expected, including pension, social security, workers compensation, commissions, royalties, disability benefits, trust income, annuities, recurring capital gains, unemployment benefits, rents, expense-sharing, dividends, interest, AFDC, SSI, food stamps, spousal support received from a prior spouse, etc. (If not known, please estimate. Put "EST" after each estimated figure.) Husband / Father Per Year Describe Per Year Wife / Mother Describe E. Total Annual Income Husband / Father Total gross annual income Total average gross monthly income 12 = Wife / Mother Total gross annual income Total average gross monthly income 12 = American LegalNet, Inc. www.FormsWorkFlow.com Initialed Income Affidavit Page 2 Less Average monthly deductions Total net monthly income = Average monthly deductions Total net monthly income Less = F. Benefits of Employment (Use of company car, country club memberships, stock options, etc.) Husband / Father Benefits Values Benefits Wife / Mother Values II. Information Required for Support Calculation: A. Minor or Dependent Children of this Marriage Child's Name Date of Birth Residing with B. Other Minor Children Living in My Household Child's Name Date of Birth Relationship C. Other Minor Children of Mine, Not Living in My Household Child's name Date of Birth Residing with OATH OF AFFIANT I, (print) hereby swear or affirm that the information set forth in this Affidavit of Income above is true, complete, and accurate. I understand that falsification of this document may result in a contempt of court finding against me which could result in a jail sentence and fine, and that falsification of this document may also subject me to criminal penalties for perjury (O.R.C. 2921.22). AFFIANT Subscribed and duly sworn before me according to law, by the above named applicant this ______ day of _______________________, _______, at _______________________, County of ___________________________, State of Ohio. ______________________________________ __________________________________________ Signature of person administering oath Title (example: Notary, Deputy Clerk of Courts, etc.) American LegalNet, Inc. www.FormsWorkFlow.com Initialed Income Affidavit Page 3