Drfa Form – Fill Out and Use This PDF

STATE OF GEORGIA

)

Petitioner,

) Civil Action No. _________

)

vs.

)

)

)

1. AFFIANT'S NAME:

Age

Spouse's Name:

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 affiant's other children:

Name(s)

Date of Birth

Resides with

(a)

Gross Monthly Income (from Item 3A)

$

-

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

$

-

(c)

Average Monthly Expenses (Item 5A)

$

-

Monthly Payments to Creditors

$

-

Total Monthly Expenses and Payments to Creditors (Item 5C)

$

-

Salary or Wages

$

-

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

$

-

Workers' Compensation Benefits

$

-

Unemployment Benefits

$

-

Judgments from Personal Injury or Other Civil Cases

$

-

Gifts (cash and 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)

$

GROSS MONTHLY INCOME

$

-

(deducting only state and federal taxes and FICA)

$

-

Affiant's Pay period (i.e., weekly, monthly, etc.)

N/A

Mortgage or rent payments

$

-

Cable TV

$

-

Property Taxes

$

-

Misc. Household & Grocery Items

$

-

Homeowner/Renter Insurance

$

-

Meals outside home

$

-

Electricity

$

-

Other

$

-

Water

$

-

Automobile

$

-

Garbage & Sewer

$

-

Gasoline and oil

$

-

Telephone

$

-

Repairs

$

-

residential line:

$

-

Auto Tags and License

$

-

cellular telephone:

$

-

Insurance

$

-

Gas

Other Vehicles

$

-

(Boats, Trailers, RVs, etc.)

$

-

Repairs & Maintenance

$

-

Gasoline and oil

$

-

Lawn Care

$

-

Repairs

$

-

Pest Control

$

-

Auto Tags and License

$

-

Insurance

$

-

CHILDREN'S' EXPENSES

Affiant's Other Expenses

Child Care (total monthly cost)

$

-

Dry Cleaning/laundry

$

-

School Tuition

$

-

clothing

$

-

Tutoring

Medical, dental, prescription (out of

$

-

pocket/uncovered expense)

$

-

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

$

-

Affiant's Gift's (special holidays)

$

-

School supplies/expenses

$

-

Entertainment

$

-

Lunch money

$

-

Recreational Expense (e.g., fitness)

$

-

Other Educational Expenses (list)

Travel expenses for visitation

$

-

______________________

$

-

Publications

$

-

______________________

$

-

Dues, clubs

$

-

Allowance

$

-

Religious and charities

$

-

Clothing

$

-

Pet Expenses

$

-

Diapers

$

-

Alimony paid to former spouse

$

-

Medical, dental, prescription (out of

Child Support paid for other children

pocket/uncovered expenses)

$

-

$

-

Grooming/hygiene

$

-

Date of initial order

_______

Gifts from Children to Others

$

-

Other (attach sheet)

$

-

Entertainment

$

-

Activities (including extra-curricular,

school, religious, cultural, etc.)

$

-

Summer Camps

$

-