Clayton County Financial Form – Fill Out and Use This PDF

,

Plaintiff,

Civil Action

vs.

Case Number ______________________________

,

Defendant.

DOMESTIC RELATIONS FINANCIAL AFFIDAVIT

(1) Your Name:

Your Age:

Spouse’s Name:

Spouse’s Age:

Date of Marriage:

Date of Separation:

Names and birth dates of children for whom support is to be determined in this action:

Name

Date of Birth

Resides with

Names and birth dates of your other children:

Name

Date of Birth

Resides with

(2) SUMMARY OF YOUR INCOME AND NEEDS: (fill out this part after you complete pages 2-5)

(A) Gross Monthly Income (from Item 3A below)

$

(B) Net Monthly Income (from Item 3B below)

$

(C) Average Monthly Expenses (Item 5A below)

$

Monthly Payments to Creditors (Item 5B below)

$

Total Monthly Expenses & Payments to Creditors (Item 5C below)

$

Domestic Relations Financial Affidavit - Rev. June 2007

Page 1 of 6

Provided by the Atlanta Legal Aid Society

Salary or Wages — ATTACH COPIES OF 2 MOST RECENT WAGE STATEMENTS

$

Commissions, Fees & Tips

$

Income from self-employment, partnership, close corporations and independent contracts

$

(gross receipts minus ordinary and necessary expenses required to produce income)

ATTACH SHEET ITEMIZING YOUR CALCULATIONS

Rental income (gross receipts minus ordinary and necessary expenses required to produce

$

income) ATTACH SHEET ITEMIZING YOUR CALCULATIONS

Bonuses

$

Overtime Payments

$

Severance Pay

$

Recurring Income from Pensions or Retirement Plans

$

Interest and Dividends

$

Trust income

$

Income from Annuities

$

Capital Gains

$

Social Security Disability or Retirement Benefits

$

Worker’s Compensation Benefits

$

Unemployment Benefits

$

Judgments from Personal Injury or Other Civil Cases

$

Gifts (cash or other gifts that can be converted to cash)

$

Prizes & Lottery Winnings

$

Alimony and maintenance from persons not in this case

$

Assets which are used for support of family

$

Fringe Benefits (if significantly reduce living expenses)

$

Any Other Income (Do not include means-tested public assistance, such as TANF or food stamps.)

$

TOTAL Gross Monthly Income (also write in 2A on page one)

$

Domestic Relations Financial Affidavit - Rev. June 2007

Page 2 of 6

Provided by the Atlanta Legal Aid Society

(2)

$

$

$

Debt owed on Vehicle (2)

$

(4) ASSETS (continued)

Separate

Separate

Basis of the Claim

Asset of

Asset of

(pre-marital, gift,

Description

Value

Husband

Wife

inheritance, etc.)

Life Insurance (net cash value)

$

$

$

Furniture / Furnishings

$

$

$

Jewelry

$

$

$

Collectibles

$

$

$

Other Assets (specify):

$

$

$

$

$

$

$

$

$

TOTAL ASSETS

$

$

$

(5)(A) AVERAGE MONTHLY EXPENSES FOR YOU AND YOUR HOUSEHOLD

HOUSEHOLD EXPENSES

Mortgage or Rent Payments

$

Gas

$

Property taxes

$

Repairs & Maintenance

$

Homeowner’s / Renter’s Insurance

$

Lawn Care

$

Electricity

$

Pest Control

$

Water

$

Cable TV / Internet Access

$

Garbage & Sewer

$

Misc. Household & Grocery Items

$

Telephones

Meals Outside Home

$

Residential Lines

$

Other (specify)

$

Cellular Telephones

$

$

AUTOMOTIVE

Gasoline & Oil

$

Auto Tags / Registration / License

$

Repairs & Maintenance

$

Insurance

$

OTHER VEHICLES (boats, trailers, RVs, etc.)

Gasoline & Oil

$

Tags / Registration / License

$

Repairs & Maintenance

$

Insurance

$

Domestic Relations Financial Affidavit - Rev. June 2007

Page 4 of 6

Provided by the Atlanta Legal Aid Society

CHILDREN’S EXPENSES

Child Care (total monthly cost)

$

Allowance

$

School Tuition

$

Children’s Clothing

$

Tutoring

$

Diapers

$

Private lessons (e.g., music, dance)

$

Medical, Dental, Prescriptions

$

(out-of-pocket uncovered expenses)

School Supplies / Expenses

$

Grooming / Hygiene

$

Lunch Money

$

Gifts from children to others

$

Other Educational Expenses (list type & amount):

Entertainment

$

______________________

$

Activities (including extra-curricular,

$

school, religious, cultural, etc.)

______________________

$

Summer Camps

$

OTHER INSURANCE

Health Insurance

$

Life Insurance

$

Children’s portion:

$

Relationship of Beneficiary:

Dental Insurance

$

Disability Insurance

$

Children’s portion:

$

Other Insurance (specify)

$

Vision Insurance

$

$

Children’s portion:

$

$

YOUR OTHER EXPENSES

Dry Cleaning & Laundry

$

Publications

$

Clothing

$

Dues, Clubs

$

Medical / Dental / Prescription

$

$

(out-of-pocket uncovered

Religious & Charities

expenses)

Your Gifts (special holidays)

$

Pet expenses

$

Entertainment

$

Alimony Paid to Former Spouse

$

Recreational Expenses (e.g., fitness)

$

Child Support Paid for other children

$

Vacations

$

Date of initial CS order:

Travel Expenses for Visitation

$

Other (attach sheet to list)

$

Domestic Relations Financial Affidavit - Rev. June 2007

Page 5 of 6

Provided by the Atlanta Legal Aid Society

TOTAL ABOVE MONTHLY EXPENSES (also write on first line of 2C on page one)

$

(5)(B) YOUR PAYMENTS & DEBTS TO CREDITORS

To Whom

Balance Due

Monthly

(Please check one)

Payments

Joint

Husband

Wife

$

$

$

$

$

$

$

$

$

$

$

$

Total Monthly Payments to Creditors (also write this total on line 2 of 2C on page one)

$

(5)(C)TOTAL MONTHLY EXPENSES

$

(Total Expenses from final line on page 5 + Total Monthly Payments to Creditors above)

(also write this total on line 3 of 2C on page one)

Daytime Phone: (

)_________________________

Domestic Relations Financial Affidavit - Rev. June 2007

Page 6 of 6

Provided by the Atlanta Legal Aid Society