Financial Affidavit {5}

IN THE CIRCUIT COURT FOR THE SECOND JUDICIAL CIRCUIT _______________________ COUNTY, ILLINOIS IN RE THE MARRIAGE OF: ___________________________, Petitioner, and ___________________________, Respondent. ) ) ) ) ) ) ) ) ) ) No. __________________ FINANCIAL AFFIDAVIT " Pre-Judgment " Post-Judgment I. INTRODUCTION I, _______________________, on oath state that my present age is ______, and that: (a) (PRE-JUDGMENT ONLY): The parties have been married for ______ years, were separated on ________________, ______, and since that time the obligor has paid $________ in child support and $________ in maintenance to the spouse: (b) (POST-JUDGMENT ONLY): The marriage of the parties was dissolved on _____________, ______. The obligor was ordered to pay $_________ child support and $_________ in maintenance to the spouse. The said order was amended ______ time(s) and the obligor is now paying $_______ in child support and $________ in maintenance. The obligor (is not) (is) presently in arrears in the sum of $________. financial affidavit 5 Rev.8/17/2011 American LegalNet, Inc. www.FormsWorkFlow.com II. PARTIES AND CHILDREN HUSBAND WIFE Name: Address: _______________________ _______________________ _______________________ Name: Address: ________________________ ___________________________ _______________________ Soc. Sec. #: XXX-XX-___ ___ ___ ___ Soc. Sec. #: XXX-XX-___ ___ ___ ___ Date of Birth: _____________ Age: _____ Employer: Occupation: _______________________ _______________________ Date of Birth: ______________ Age: ________ Employer: Occupation: ___________________________ ___________________________ CHILDREN Name ____________________ ____________________ ____________________ ____________________ Date of Birth ____________ ____________ ____________ ____________ Age ________ ________ ________ ________ With Whom Residing ___________________________ ___________________________ ___________________________ ___________________________ III. STATEMENT OF INCOME. IMPORTANT: Attach most recent of last three months= pay stubs showing your year-to-date earnings and deductions. For those individuals who receive any income from self-employment sources, attach supporting documentation for year-to-date earnings. HUSBAND WIFE GROSS MONTHLY INCOME from: Salary, wages, commissions, bonuses, allowance & overtime (NOTE: To arrive at gross monthly income, multiply weekly gross by 52 and divide by 12, or multiply bi-weekly income by 26 and divide by 12) Pension or retirement benefits $_______________ $_______________ $______________ $______________ financial affidavit 5 Rev.8/17/2011 American LegalNet, Inc. www.FormsWorkFlow.com Social Security benefits Disability or unemployment benefits Public aid (ADC-Welfare) Child support from prior marriage (alimony) Rents Other Income (specify): _________________________ _________________________ TOTAL GROSS MONTHLY INCOME DEDUCTIONS: $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $______________ $______________ $______________ $______________ $______________ $______________ $______________ $______________ $______________ Federal income tax withheld State income tax withheld Social Security withheld Medical or other health-related insurance Mandatory retirement contributions required as a condition of employment Union Dues Dependent and individual health/hospital insurance premiums Prior Court ordered support and/or maintenance, actually paid pursuant to a Court Order Other deductions permitted by 750 ILCS '505(a)(3)(h) C specify: ___________________________ ___________________________ $_______________ $_______________ $_______________ $_______________ $_______________ $______________ $______________ $______________ $______________ $______________ $_______________ $______________ $_______________ $______________ $_______________ $______________ $_______________ $_______________ $_______________ $______________ $______________ $______________ TOTAL NET MONTHLY INCOME $_______________ $______________ financial affidavit 5 Rev.8/17/2011 American LegalNet, Inc. www.FormsWorkFlow.com IV. ESTIMATED MONTHLY EXPENSES (*mark if a projected expense C Affiant must be prepared to submit testimony to support the same) HOUSEHOLD: Rent or house payment (specify) Repair and upkeep Housekeeper and yard work Homeowners= or renters= insurance Real estate taxes (not included in house payment) Other (specify): __________________________________ __________________________________ __________________________________ SUBTOTAL UTILITIES: $__________________________ $__________________________ $__________________________ $__________________________ $__________________________ $__________________________ $__________________________ $__________________________ $__________________________ Electricity Gas/Heating oil Water and sewer Telephone Trash removal Cable TV Other (specify): __________________________________ __________________________________ __________________________________ SUBTOTAL financial affidavit 5 $__________________________ $__________________________ $__________________________ $__________________________ $__________________________ $__________________________ $__________________________ $__________________________ $__________________________ $__________________________ Rev.8/17/2011 American LegalNet, Inc. www.FormsWorkFlow.com FOOD: Food, milk, household supplies School lunches Meals outside home Other (specify): __________________________________ __________________________________ __________________________________ SUBTOTAL CLOTHING: $__________________________ $__________________________ $__________________________ $__________________________ $__________________________ $__________________________ $__________________________ Clothing (self) Clothing (children) Laundry & dry cleaning Other (specify): __________________________________ SUBTOTAL MEDICAL CARE: (after insurance reimbursement) $__________________________ $__________________________ $__________________________ $__________________________ $__________________________ Doctor & Dentist (self) Drugs & medical supplies (self) Doctor & dentist (children) Drugs & medical supplies (children) Medical and dental insurance Other: __________________________________ __________________________________ SUBTOTAL financial affidavit 5 $__________________________ $__________________________ $__________________________ $___