Financial Affidavit

Affidavit - Financial AFDFINAC (11/01) UNITED STATES OF AMERICA STATE OF ILLINOIS COUNTY OF LASALLE IN THE CIRCUIT COURT OF THE THIRTEENTH JUDICIAL CIRCUIT ____________________________ Petitioner - VS Pre-Judgment Post-Judgment No.: ____________________________ Respondent ____________________ FINANCIAL AFFIDAVIT _______________________________________________________, on oath states that my present age is _______, and that: 1. (a) (PRE-JUDGMENT ONLY): The parties have been married for _______ years, were seperated on _________________________, 20_______, and since that time the husband has paid $_______________ in child support and $_______________ in maintenance to his spouse; (b) (POST-JUDGMENT ONLY): The marriage of the parties was dissolved on _________________________, 20_______. The husband was ordered to pay $_______________ child support and $_______________ in maintenance to his spouse. The said order was amended _______ times and the husband is now paying $________________ in child support and $_______________ in maintenance. The husband (is/is not) presently in arrears in the sum of $_______________. 2. There are _______ children of the marriage, aged ______________________________, and presently in the custody of _________________________ _______________________________________________________. 3. I have additional persons dependant on me for support as follows: NAME ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ 4. My MONTHLY living expenses are as follows: Rent or House Payment.............................. $_______________ Electricity.................................................. Gas............................................................ Heating Oil................................................ Water......................................................... Telephone.................................................. Trash Collection......................................... Sewer Charges........................................... Groceries/Household Supplies................... Restaurant Meals....................................... Charitable Contributions............................ Haircuts/Beauty Shop................................ Union Dues................................................ Babysitting................................................. $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ Car Insurance.................................................... Gas, Oil, & Repairs........................................... Medical/Hospital Insurance............................... Life Insurance.................................................... Personal Items................................................... Doctors............................................................. Dentists............................................................ Hospital............................................................ $______________ $______________ $______________ $______________ $______________ $______________ $______________ $______________ RELATIONSHIP ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ School Expenses (Meals/Supplies)................. $______________ Cleaning & Laundry ......................................... Entertainment................................................... $______________ $______________ Gifts/Toys/Books for children............................ $______________ Other:_________________________________ $______________ ______________________________________ $______________ Total Monthly Living Expenses $______________________ American LegalNet, Inc. www.FormsWorkFlow.com LASALLE COUNTY CIRCUIT CLERK OTTAWA, ILLINOIS 61350 5. DEBTS: (payments to creditors other than noted at #4 above) TO WHOM OWED: PURPOSE: Car Payment................................ ..... Furniture/Appliance.......................... Credit Card (___________________) Credit Card (___________________) ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ AFDFINAC-2(11/95) PAYMENT/MONTH: $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ BALANCE OWED: $____________________ $____________________ $____________________ $____________________ $____________________ $____________________ $____________________ $____________________ $____________________ $____________________ $____________________ (a)_______________________________ (b)_______________________________ (c)_______________________________ (d)_______________________________ (e)_______________________________ (f)_______________________________ (g)_______________________________ (h)_______________________________ (i)_______________________________ (j)_______________________________ (k)_______________________________ 6. INCOME: Present Employer_________________________________________ Hours of Employment....................................... Hourly Wage.................................................... Weekly Gross Income....................................... Total Deductions.............................................. Take-Home Pay................................................ Number of Dependants Claimed....................... 7. ______________ $______________ $______________ $______________ $______________ ______________ Address________________________________________________ PAYROLL DEDUCTIONS (a) Taxes............... ........................................... $_____________ (b) Social Security............................................ (c) Medical Insurance....................................... (d) Credit Union............................................... (e) Other.......................................................... Total Deductions.............................................. $_____________ $_____________