In the Superior Court of Gwinnett County, Georgia

In the Superior Court ofGwinnett County, Georgia

)

______, Plaintiff)

)

vs.) Civil Action No. ______

)

______, Defendant)

)

DOMESTIC RELATIONS FINANCIAL AFFIDAVIT

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 / Date of Birth / Resides with

______

______

______

2.SUMMARY OF AFFIANT’S INCOME AND NEEDS

(a) Gross monthly income (from item 3A)$ ______

(b) Net monthly income (from item 3C) ______

(c) Average monthly expenses (item 5A)$ ______

Monthly payments to creditors+ ______

Total monthly expenses and payments

to creditors (item 5C) ______

3. A. AFFIANT’S GROSS MONTHLY INCOME (complete this section or attach Child Support Schedule A)

(All income must be entered based on monthly average regardless of date of receipt.)

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$ ______

Workers’ 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)$ ______

GROSS MONTHLY INCOME$ ______

1. Affiant’s Net Monthly Income from employment

(deducting only state and federal taxes and FICA)$ ______

Affiant’s pay period (i.e., weekly, monthly, etc.) ______

Number of exemptions claimed ______

4. 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 and state the amount and the basis: pre-marital, gift, inheritance, source of funds, etc.).

Description / Value / Separate Asset
of the Husband / Separate Asset
of the Wife / Basis of the
Claim
Cash / $______/ ______/ ______/ ______
Stocks, bonds / $______/ ______/ ______/ ______
CD’s/Money Market
Accounts / $______/ ______/ ______/ ______
Bank Accounts
(list each account):
______/ $______/ ______/ ______/ ______
______/ $______/ ______/ ______/ ______
______/ $______/ ______/ ______/ ______
Retirement Pensions,
401K, IRA, or
Profit Sharing / $______/ ______/ ______/ ______
Money owed you: / $______/ ______/ ______/ ______
Tax Refund
owed you: / $______/ ______/ ______/ ______
Real Estate:
home:
debt owed: / $ ______
$ ______/ ______/ ______/ ______
other:
debt owed: / $______
$ ______/ ______/ ______/ ______
Automobiles/Vehicles:
Vehicle 1:
debt owed: / $______
$ ______/ ______/ ______/ ______
Vehicle 2:
debt owed: / $______
$______/ ______/ ______/ ______
Life Insurance
(net cash value): / $______/ ______/ ______/ ______
Furniture/furnishings: / $______/ ______/ ______/ ______
Jewelry: / $______/ ______/ ______/ ______
Collectibles: / $______/ ______/ ______/ ______
Other Assets: / $______/ ______/ ______/ ______
______/ $______/ ______/ ______/ ______
______/ $______/ ______/ ______/ ______
______/ $______/ ______/ ______/ ______
Total Assets: / $______/ ______/ ______/ ______

5. A. AVERAGE MONTHLY EXPENSES

HOUSEHOLD
Mortgage or rent payments / $ ______/ Cable TV / $ ______
Property taxes / $ ______/ Misc. household and grocery
Items / $ ______
Homeowner/Renter Insurance / $ ______/ Meals outside the home / $ ______
Electricity / $ ______/ Other / $ ______
Water / $ ______/ AUTOMOBILE
Garbage and Sewer / $ ______/ Gasoline and oil / $ ______
Telephone:
residential line:
cellular telephone: / $ ______
$ ______/ Repairs
Auto tags and license
Insurance / $ ______
$ ______
$ ______
Gas / $ ______/ OTHER VEHICLES
(boats, trailers, RVs, etc.)
Repairs and maintenance: / $ ______/ Gasoline and oil / $______
Lawn Care / $ ______/ Repairs / $______
Pest Control / $ ______/ 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 expenses) / $______
Private lessons (e.g., music, dance) / $______/ Affiant’s gifts (special holidays) / $______
School supplies/expenses / $______/ Entertainment / $______
Lunch Money / $______/ Recreational Expenses (e.g., fitness) / $______
Other Educational Expenses (list) / Vacations / $______
______/ $______/ Travel Expenses for Visitation / $______
______/ $______/ Publications / $______
Allowance / $______/ Dues, clubs / $______
Clothing / $______/ Religious and charities / $______
Diapers / $______/ Pet expenses / $______
Medical, dental, prescription
(out of pocket/uncovered expenses) / $______/ Alimony paid to former spouse / $______
Grooming, hygiene / $______/ Child support paid for other children / $______
Gifts from children to others / $______/ Date of initial order: / ______
Entertainment / $______/ Other (attach sheet) / $______
Activities (including extra-curricular,
school, religious, cultural, etc.) / $______
Summer Camps / $______
OTHER INSURANCE
Health
Child(ren)’s portion: / $______/ $______
Dental
Child(ren)’s portion: / $______/ $______
Vision
Child(ren)’s portion: / $______/ $______
Life
Relationship of Beneficiary: / $______/ ______
Disability / $______
Other(specify): / $______

TOTAL ABOVE EXPENSES$ ______

B. PAYMENTS TO CREDITORS / (please check one)
To Whom: / Balance Due / Monthly Payment / Joint / Plaintiff / Defendant

TOTAL MONTHLY PAYMENTS TO CREDITORS:$ ______

C. TOTAL MONTHLY EXPENSES:$ ______

This ______day of ______, 20______.

______

Notary PublicAffiant

1

MAG 60-44 Domestic Relations Affidavit