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Office of Dispute Resolution

SEVENTH JUDICIAL ADMINISTRATIVE DISTRICT

P.O. BOX 963 PHONE: (770) 387-4820

CARTERSVILLE, GA 30120 TOLL FREE: (877) 655-6865

FAX: (770) 387-5479

IN THE SUPERIOR COURT OF ______COUNTY

STATE OF GEORGIA

______,*

*

Plaintiff,*

*Civil Action

Vs.*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 Resides With

______

  1. 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 (Item 5B)+______

Total monthly expenses and payments

To creditors (Item 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 and

Similar payments (based on past 12 month average or

Time of employment if less that a year). ATTACH
SHEETS ITEMIZING THIS INCOME, ______

Business income from sources such as self employment,

Partnership, close corporations, and/or independent

Contracts (gross receipts minus ordinary and necessary

Expenses required to produce income), ATTACH SHEET

ITEMIZING THIS INCOME.______

Disability / unemployment, / worker’s comp______

Pension, retirements or annuity payments______

Other public benefits (specify)______

Social Security benefits______

Spousal or child support from prior marriage______

Interest and dividends______

Rental income (gross receipts minus ordinary and

Necessary expenses required to produce income)

ATTACH SHEET ITEMIZING THIS INCOME______

Income from royalties, trusts or estate______

Gains derived from dealing in property (not including

Non-recurring gains).______

Other income of a recurring nature (specify source)______

GROSS MONTHLY INCOME$______

  1. List and describe all benefits of employment, e.g., automobile 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.

______

  1. 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:______

  1. Assets (if you claim or agree that all or part of an asset in 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).

DescriptionValueSeparate AssetSeparate Asset

of Husband of Wife

Cash$______

Stocks, bonds$______

CDs/Money Mkt Accts $______

Real Estate:
Home$______

Other$______

$______

Automobile$______

Money Owed You$______

Retirement/IRA$______

Furniture/furnishings$______

Jewelry$______

Life Insurance$______

(cash value)

Collectibles$______

Bank accounts

Checking$______

Savings$______

Other Assets

______$______

TOTAL ASSETS$______

  1. A. (Indicate with (*) all which are estimates rather than actual figures than actual figures

Taken from records or personal knowledge).

AVERAGE MONTHLY EXPENSES

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HOUSEHOLD:

Mortgage/Rent payments______

Property taxes______

Insurance______

Electricity______

Water______

Garbage/Sewer______

Telephone______

Gas______

Repairs/Maintenance______

Lawn care______

Pest control______

Cable TV______

Misc. Household______

Grocery items______

Meals outside of home______

Other (specify)______

TOTAL HOUSEHOLD EXPENSES ______

AUTOMOBILE

Gasoline______

Insurance______

Repairs______

Auto tags and license______

Other (specify)______

TOTAL AUTOMOBILE EXPENSES ______

CHILDREN’S EXPENSE

Childcare______

School tuition______

School supplies/expenses______

Lunch money______

Clothing______

Diapers______

Medical, dental, prescription______

Grooming/hygiene______

Gifts______

Entertainment______

Activities______

INSURANCE

Health______

Life______

Disability______

Other______

AFFIANT’S OTHER EXPENSES:

Dry cleaning______

Laundry______

Clothing______

Medical/dental______

Prescriptions______

Gifts (special holidays)______

Hygiene/grooming______

Entertainment______

Vacations______

Publications______

Dues/clubs______

Religious______

Charities______

Misc. (attach sheet)______

Other (attach sheet)______

Alimony paid______

(to former spouse)

Child support paid______

(to former spouse)

TOTAL OTHER EXP.$______

TOTAL MONTHLY EXPENSES$______

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B. PAYMENT TO CREDITORS:

To whom: (with account #)Balance DueMonthly Payments

______

______

______

______

______

______

TOTAL MONTHLY PAYMENTS TO CREDITORS$______

C. TOTAL MONTHLY EXPENSES$______

Sworn to and subscribed

Before me this ____day

Of ______, 20___.

______

Notary PublicAffiant

Services are provided and admissions/referrals are made without regard to race, color, religious creed, ancestry, gender, sexual orientation, disability, age or national origin. Complaints of discrimination may be filed with the Seventh Administrative District Office.