Plaintiff / Case No.
-vs-
COUNTER-AFFIDAVIT
Defendant
STATE OF OHIO / )
) / ss.
COUNTY OF CRAWFORD / )
The / being duly sworn, says that the answers to the following
questions are true to the best of / knowledge and belief.
(A) GENERAL:
Indicate by letter and number any responses in the affidavit filed by your spouse to which you disagree or would like to explain further and state specifically your disagreement or explanation.
(B) INCOME:
1. List current average gross earnings, deductions from pay (such as federal, state and city income
taxes, Social Security, credit union, etc.) and take home pay (specify pay period and convert to
monthly rate): (a) for self; (b) for spouse:
1(a) / 1(b)
2. Other sources of income such as “away from home” expenses paid by employer, child support
paid by another party, rentals, etc. (specify period and convert to monthly rate):
(a) for self; (b) for spouse:
2(a) / 2(b)
Verification and Explanation – The answers to this part are subject to the same verification and
explanation requirements of the affidavit.
(C) ORDINARY EXPENSES: For each specify amount and period then convert to monthly rate.
3(a) Rent or house payment / 3(a)
If owned, does payment cover: / (b)
(b) Taxes and (c) Insurance / (c)
If not, specify:
(C) ORDINARY EXPENSES - CONTINUED
4(a) Car operating expenses, gas, oil / 4(a)(b) Maintenance, and / (b)
(c) Insurance / (c)
5. Utilities (specify if on budget)
(a) Gas, fuel oil / 5(a)
(b) Electric / (b)
(c) Water / (c)
(d) Phone (specify base rate and / (d)
necessity for long distance calls)
(e) Garbage / (e)
(f) Cable TV / (f)
(g) Other / (g)
6. Food and groceries (with spouse / 6.
absent)
7. Clothing (required during / 7.
temporary order)
8. Dry cleaning and laundry / 8.
9. Insurance
(a) Medical / 9(a)
(b) Life (describe policies) / (b)
(c) Other not covered in 3(c) and / (c)
4(c) (specify)
10. School lunches / 10.
11. Baby-sitting (specify to whom / 11.
paid and hourly rate)
12. Miscellaneous (specify generally) / 12.
(D) SUMMARY ON MONTHLY BASIS:
13. Your take home pay (Item 1(a)) / 13.
14. Spouse’s take home pay (Item 1(b)) / 14.
15. Other income (Item 2) / 15.
16. Total of expenses listed in Item C / 16.
17. Total of payments on indebtedness / 17.
X
Sworn to before me and subscribed in my presence this / day of / , / .
Notary Public
WHEREFORE, / prays for:
1. Child support in the amount of / $ / per week per child.
2. Temporary spousal support in the amount of / $ / per week.
3. Counsel fees of / $ / .
(NOTE: Convert to monthly rate in the same manner as described on the affidavit.)