In the Superior Court of ______ County

In the Superior Court of ______County

State of Georgia

______,

Plaintiff

Civil Action

File No. ______

______,

Defendant,

DOMESTIC RELATIONS FINANCIAL AFFIDAVIT

1. Affiant’s name: ______Age: ______

Affiant’s Social Security No. ______

Spouse’s Name: ______Age: ______

Date of Marriage: ______Date of Separation: ______

Names and birthdates of children of this marriage:

Name Date of Birth Resides With

______

______

Names and birthdates of children of prior marriage(s) residing with Affiant:

Name Date of Birth

______

______

______

2.  SUMMARY OF AFFIANT’S INCOME AND NEEDS

A) Gross monthly income (3A) $______

B) Net monthly income (3C) $______

C) Average monthly expenses (5A) $______

Monthly Payments to creditors (5B) +______

Total monthly expenses & payments

to creditors (5C) $______

D)  Amount of spousal/child support

needed by Affiant $______

E)  Amount of child support indicated

by child support guidelines $______

3. A. Affiant’s Gross Monthly Income:

(All income must be entered based on monthly average regardless of date of receipt. Where applicable, income should be annualized)

Salary: $______

Bonuses, commissions allowances,

overtime, tips & similar payments (based

on 12-month average or time of

employment if loss than q. year).

ATTACH SHEETS ITEMIZING INCOME $______

Business income from sources such as self-

Employment, partnership, closed corp., and/

or independent contracts (gross receipts less

ordinary & necessary expenses required to

produce income). ATTACH SHEET

ITEMIZING THIS INCOME $______

Disability/unemployment/work comp $______

Pension, retirement or annuity pymts $______

Other public benefits (specify) $______

Social Security benefits $______

Spousal or child support from prior $______

Interest and dividends $______

Rental income (gross receipts less

ordinary & necessary expenses

required to produce income

ATTACH SHEET ITEMIZING THIS $______

Income from royalties, trusts or estates $______

Gains derived from dealings in property

(not including non-recurring gains) $______

Other income of a recurring nature

(specify source) $______

GROSS MONTHLY INCOME $______

B. List and describe all benefits of employment, e.g.: auto and/or auto allowance insurance (auto, life, disability, etc.), deferred compensation, employer contribution to retirement or stock, club memberships, and reimbursed expenses (to the extent they reduce personal living expenses). ATTACH SHEET, IF NECESSARY.

C.  Net monthly income from employment

(deducting only state & federal taxes &

FICA) $______

Affiant’s pay period (weekly, monthly) ______

Number of exemptions ______

3.  Assets (if you claim or agree that all or part of an asset is non-marital, indicate the non-marital portion, under the appropriate spouse’s column. The total value of each asset must be listed in the “value” column. “Value” means what you feel the item of property would be worth if it were offered for sale).

Description Value Separate Asset Separate Asset

of Husband of Wife

Cash $______

Stocks, bonds $______

CDs/Money

Market Acct $______

Real Estate:

Home $______

Other $______

$______

Car $______

Car #2 $______

Money owed

to you $______

IRA/Retire $______

Furniture/

Furnishings $______

Jewelry $______

Life Ins. $______

(cash value)

Collectibles $______

Bank Accounts

Checking $______

Savings $______

Other Assets

______$______

TOTAL

ASSETS $______

4.  A. (Indicate with (*) all which are estimates rather than actual figures taken from records or personal knowledge).

AVERAGE MONTHLY EXPENSES

HOUSEHOLD: INSURANCE:

Mort/Rent ______Health ______

Prop Taxes ______Life ______

Insurance ______Disability ______

Electricity ______Other ______

Water ______

Garbage/Sewer ______AFFIANT’S OTHER EXPENSES

Telephone ______Dry Cleaning ______

Gas ______Laundry ______

Repairs/Maint. ______Clothing ______

Lawn Care ______Medical/Dental ______

Pest Control ______Prescriptions ______

Cable TV ______Gifts (special hol) ______

Misc. HH ______Hygiene/grooming ______

Grocery items ______Entertainment ______

Meals Out ______Vacations ______

Other (specify) ______Publications ______

Dues, clubs ______

TOTAL HH EXP. $______Religious ______

Charities ______

AUTOMOBILE Misc. (sheet) ______

Gas& Oil ______Other (sheet) ______

Insurance ______Alimony Paid ______

Repairs ______(to former spouse)

Auto tags & lics ______Child support paid ______

Other (specify) ______to former spouse)

TOTAL AUTO EXPENSE $______TOTAL OTHER EXP. $______

CHILDREN’S EXPENSES

Child care ______

School Tuition ______

School supplies ______

Lunch money ______

Clothing ______

Diapers ______TOTAL MONTHLY EXPENSES

Medical, dental ______

Grooming/hygiene ______$______

Gifts ______

Entertainment ______

Activities ______

B. PAYMENT TO CREDITORS:

To Whom (with account #) Balance Due Monthly Payments

______

______

______

______

______

Total Monthly Payments ______

C. TOTAL MONTHLY EXPENSES $______

Sworn to and subscribed before me

this ______day of ______,

20___.

______

Notary Public Affiant

1