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Supreme Court of Ohio Uniform Domestic Relations Form – Affidavit 1 AFFIDAVIT OF BASIC INFORMATION, INCOME, AND EXPENSES Approved under Ohio Civil Rule 84 Amended: September 21, 2020 Page 1 of 7
IN THE COURT OF COMMON PLEAS ________________________ DIVISION ___________________ COUNTY, OHIO
Case No. ________________________
Judge ___________________________
Magistrate _______________________
_____________________________ Plaintiff/Petitioner 1
vs./and
_____________________________ Defendant/Petitioner 2
Instructions: Check local court rules to determine when this form must be filed. This affidavit is used to make complete disclosure of income, expenses, and money owed. It is used to determine child and spousal support. Do not leave any category blank. For each item, if none, put “NONE.” If you do not know exact figures for any item, give your best estimate, and put “EST.” If you need more space, add additional pages.
AFFIDAVIT OF BASIC INFORMATION, INCOME, AND EXPENSES
Affidavit of ___________________
Date of marriage ___________________ Date of separation ___________________
SECTION I – BASIC INFORMATION Plaintiff/Petitioner 1 Defendant/Petitioner 2
Date of Birth _____________________________ Date of Birth _____________________________
Social Security Number _____________________ Social Security Number _____________________
Phone Number ___________________________ Phone Number ___________________________ Health:
Good Fair Poor
If health is not good, please explain:
Health: Good Fair Poor
If health is not good, please explain:
Page 2 of 7
Education: (Check highest level achieved) Grade School High School Associate Bachelor’s Post Graduate
Education: (Check highest level achieved) Grade School High School Associate Bachelor’s Post Graduate
Other Technical Certifications:
Active Member of the U.S. Military Yes No
Other Technical Certifications:
Active Member of the U.S. Military Yes No
SECTION II – INCOME Plaintiff/Petitioner 1 Defendant/Petitioner 2
Yes No Yes No ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________
Employed Date of Employment
Name of Employer Payroll Address
Payroll City, State, Zip Scheduled Paychecks Per Year 12 24 26 52 12 24 26 52
A. YEARLY INCOME, OVERTIME, COMMISSIONS, AND BONUSES FOR PAST THREE YEARS
Plaintiff/Petitioner 1 Year $___________________ 3 years ago 20__
Base yearly income $___________________ 2 years ago 20__ $___________________ Last year 20__
Yearly overtime, commissions, and/or bonuses
$___________________ 3 years ago 20__ $___________________ 2 years ago 20__ $___________________ Last year 20__
Defendant/Petitioner 2 $ _________________ $ _________________ $ _________________
$ _________________$ _________________$ _________________
B. COMPUTATION OF CURRENT INCOME
Plaintiff/Petitioner 1 Defendant/Petitioner 2
$_________________ $_________________ Base Yearly Income
Average yearly overtime, commissions, and/or bonuses over last 3 years (from part A)
Supreme Court of Ohio Uniform Domestic Relations Form – Affidavit 1 AFFIDAVIT OF BASIC INFORMATION, INCOME, AND EXPENSES Approved under Ohio Civil Rule 84 Amended: September 21, 2020
$_________________ $_________________
Page 3 of 7
$_________________ $_________________ Unemployment Compensation Disability Benefits
Workers’ Compensation Social Security Other: ________________ $_________________ $_________________
Retirement Benefits Social Security Other: ________________ $_________________ $_________________
$_________________ $_________________
$_________________ $_________________
$_________________ $_________________
$_________________ $_________________
$_________________ $_________________
Spousal Support Received
Interest and dividend income (source) __________________
Other income (type and source) _________________________
TOTAL YEARLY INCOME
Supplemental Security Income (SSI) or public assistance
Court-ordered child support that you receive for minor and/or dependent child(ren) not of the marriage or relationship $_________________ $_________________
SECTION III – CHILDREN AND HOUSEHOLD RESIDENTS
Minor and/or dependent child(ren) who is/are adopted or born from this marriage or relationship:
Name __________________________ __________________________ __________________________ __________________________
Date of birth _________________ _________________ _________________ _________________
Living with ______________________ ______________________ ______________________ ______________________
In addition to the above child(ren): Plaintiff/Petitioner 1 has _________ other minor biological or adopted child(ren). Defendant/Petitioner 2 has _________ other minor biological or adopted child(ren). There is/are _________ adult(s) in your household.
Supreme Court of Ohio Uniform Domestic Relations Form – Affidavit 1 AFFIDAVIT OF BASIC INFORMATION, INCOME, AND EXPENSES Approved under Ohio Civil Rule 84 Amended: September 21, 2020
Page 4 of 7
SECTION IV – EXPENSES
List monthly expenses below for your present household.
A. MONTHLY HOUSING EXPENSES
Rent or first mortgage (including taxes and insurance) $_________________ Second mortgage/equity line of credit $_________________ Real estate taxes (if not included above) $_________________ Renter or homeowner's insurance (if not included above) $_________________ Homeowner or condominium association fee $_________________ Utilities ° Electric $_________________
° Gas, fuel oil, propane $_________________ ° Water and sewer $_________________ ° Telephone and/or cell phone $_________________ ° Trash collection $_________________ ° Cable/satellite television $_________________ ° Internet service $_________________ Cleaning $_________________ Lawn service and/or snow removal $_________________ Other: _____________________________________________________ $_________________
_____________________________________________________ $_________________ TOTAL MONTHLY: $_________________
B. OTHER MONTHLY LIVING EXPENSES
Food ° Groceries (including food, paper, cleaning products, toiletries, and other) $_________________ ° Restaurant $_________________
Transportation ° Vehicle loan, lease $_________________ ° Vehicle maintenance $_________________ ° Gasoline $_________________ ° Parking, public transportation $_________________
Clothing
° Clothes (other than child(ren)’s)
Supreme Court of Ohio Uniform Domestic Relations Form – Affidavit 1 AFFIDAVIT OF BASIC INFORMATION, INCOME, AND EXPENSES Approved under Ohio Civil Rule 84 Amended: September 21, 2020
$_________________
Page 5 of 7
° Dry cleaning and laundry $_________________ Personal grooming ° Hair and nail care $_________________ ° Other: ___________________________________________________ $_________________
Other: _____________________________________________________ $_________________ TOTAL MONTHLY: $_________________
C. MONTHLY MINOR CHILD-RELATED EXPENSES(for child(ren) of the marriage or relationship)
Work and/or education-related child care $_________________ Other child care $_________________ Extraordinary parenting time travel cost $_________________ School tuition $_________________ School lunches $_________________ School supplies $_________________ Extracurricular activities and lessons $_________________ Clothing $_________________ Child(ren)’s allowances $_________________ Special and extraordinary needs of child(ren) (not included elsewhere) $_________________ Other: _____________________________________________________ $_________________
TOTAL MONTHLY: $_________________
D. MONTHLY INSURANCE PREMIUMS
Life $_________________ Auto $_________________ Health $_________________ Disability $_________________ Other: _____________________________________________________ $_________________
TOTAL MONTHLY: $_________________
E. MONTHLY WORK AND EDUCATION EXPENSES FOR SELF
Mandatory work expenses (union dues, uniforms, or other) $_________________ Additional income taxes paid (not deducted from wages)
Supreme Court of Ohio Uniform Domestic Relations Form – Affidavit 1 AFFIDAVIT OF BASIC INFORMATION, INCOME, AND EXPENSES Approved under Ohio Civil Rule 84 Amended: September 21, 2020
$_________________
Supreme Court of Ohio Uniform Domestic Relations Form – Affidavit 1 AFFIDAVIT OF BASIC INFORMATION, INCOME, AND EXPENSESApproved under Ohio Civil Rule 84 Amended: September 21, 2020
Page 6 of 7
Tuition $_________________ Books, fees, and other $_________________ College loan $_________________ Other: _____________________________________________________ $_________________
_____________________________________________________ $ _________________ TOTAL MONTHLY: $_________________
F. MONTHLY HEALTH CARE EXPENSES(not covered by insurance)
Physicians $_________________ Dentists and orthodontists $_________________ Optometrists and opticians $_________________ Prescriptions $_________________ Other: _____________________________________________________ $_________________
TOTAL MONTHLY: $_________________
G. MISCELLANEOUS MONTHLY EXPENSES
Extraordinary obligations for other minor/handicapped child(ren) [for child(ren) who were not born of this marriage or relationship and were not adopted by these parties] $_________________ Child support for child(ren) who were not born of this marriage or relationship and were not adopted by these parties $_________________ Expenses paid for adult child(ren) or other dependent(s) $_________________ Spousal support paid to former spouse(s) $_________________ Subscriptions and books $_________________ Charitable contributions $_________________ Memberships (associations and clubs) $_________________ Travel and vacations $_________________ Pets $_________________ Gifts $_________________ Attorney fees $_________________
$_________________ _____________________________________________________ $_________________
TOTAL MONTHLY: $_________________
Other:_____________________________________________________
Supreme Court of Ohio Uniform Domestic Relations Form – Affidavit 1 AFFIDAVIT OF BASIC INFORMATION, INCOME, AND EXPENSES Approved under Ohio Civil Rule 84 Amended: September 21, 2020 Page 7 of 7
H. MONTHLY INSTALLMENT PAYMENTS INCLUDING BANKRUPTCY PAYMENTS(Do not repeat expenses already listed.)Examples: car, credit card, rent-to-own, or cash advance payments
To whom paid Purpose Balance due Monthly payment __________________ __________________ __________________ $___________________ __________________ __________________ __________________ $___________________ __________________ __________________ __________________ $___________________ __________________ __________________ __________________ $___________________ __________________ __________________ __________________ $___________________ __________________ __________________ __________________ $___________________ __________________ __________________ __________________ $___________________ __________________ __________________ __________________ $___________________ __________________ __________________ __________________ $___________________ __________________ __________________ __________________ $___________________ __________________ __________________ __________________ $___________________ __________________ __________________ __________________ $___________________ __________________ __________________ __________________ $___________________
TOTAL MONTHLY: $___________________
GRAND TOTAL MONTHLY EXPENSES (Sum of A through H): $___________________
OATH OR AFFIRMATION (Do not sign until Notary Public is present)
I, (print name) ____________________, swear or affirm that I have read this Affidavit and, to the best of my knowledge and belief, the facts and information stated in this Affidavit are true, accurate, and complete. I understand that if I do not tell the truth, I may be subject to penalties for perjury.
___________________________________ Your Signature STATE OF ___________________ )
) SSCOUNTY OF _________________ )
Sworn to or affirmed before me by _____________________this _____day of ____________,______.
___________________________________ Signature of Notary Public
___________________________________ Printed Name of Notary PublicCommission Expiration Date: ___________(Affix seal here)
DIVISION: COUNTY OHIO: PlaintiffPetitioner 1: Case No: Judge: Magistrate: DefendantPetitioner 2: Affidavit of: Date of marriage: Date of separation: Date of Birth: Date of Birth_2: Social Security Number: Social Security Number_2: Phone Number: Phone Number_2: Good: OffFair: OffPoor: OffGood_2: OffFair_2: OffPoor_2: OffIf health is not good please explain: If health is not good please explain_2: Grade School: OffHigh School: OffAssociates: OffGrade School_2: OffHigh School_2: OffAssociates_2: OffBachelors: OffPost Graduate: OffBachelors_2: OffPost Graduate_2: OffOther Technical Certifications: Other Technical Certifications_2: 1: 2: 3: 4: 1_2: 2_2: 3_2: 4_2: 12: Off24: Off26: Off52: Off12_2: Off24_2: Off26_2: Off52_2: OffPlaintiffPetitioner 1_2: undefined_2: undefined_3: undefined_4: undefined_5: undefined_6: Workers Compensation: OffSocial Security: OffOther: OffSocial Security_2: OffOther_2: OffLawn service andor snow removal 1: To whom paid 1: To whom paid 2: To whom paid 3: To whom paid 4: To whom paid 5: To whom paid 6: To whom paid 7: To whom paid 8: To whom paid 9: To whom paid 10: To whom paid 11: To whom paid 12: To whom paid 13: Purpose 1: Purpose 2: Purpose 3: Purpose 4: Purpose 5: Purpose 6: Purpose 7: Purpose 8: Purpose 9: Purpose 10: Purpose 11: Purpose 12: Purpose 13: Balance due 1: Balance due 2: Balance due 3: Balance due 4: Balance due 5: Balance due 6: Balance due 7: Balance due 8: Balance due 9: Balance due 10: Balance due 11: Balance due 12: Balance due 13: undefined_8: 0Text2: Text3: Text4: Text5: Text6: Text7: Text8: Text9: Text10: Text11: Text12: Text13: Text14: Text15: Text16: Text17: Text18: Text19: Text20: Text21: Text22: Text23: Text24: 0Text25: 0Text26: Text27: Text28: Text29: Text1: Text30: Text31: Text32: Text33: Text34: Text35: Text36: Text37: Text38: Text39: Text40: Text41: Text42: Text43: Text44: Text46: Text47: Text48: Text49: Text50: Text51: Text52: Text53: Text54: Text55: Text56: Text57: Text58: Text59: Text62: Text63: Text64: Text65: Text66: Text67: Text68: Text69: Text70: Text71: Text72: 0Text74: Text75: Text77: Text78: Text79: Text80: Text82: Text83: Text85: Text86: Text87: Text88: 0Text89: Text90: Text91: Text92: Text93: Text94: Text95: Text96: Text97: Text98: Text99: Text100: 0Text101: Text102: Text103: Text104: Text105: Text106: 0Text107: Text108: Text109: Text110: Text111: Text112: Text113: Text114: 0Text115: Text116: Text117: Text118: Text119: Text120: 0Text121: Text122: Text123: Text124: Text125: Text126: Text127: Text128: Text129: Text130: Text131: Text132: Text133: Text134: 0Text136: Text137: Text138: Text139: Text140: Text141: Text142: Text143: Text144: Text145: Text146: Text147: Text148: Text149: 0Check Box150: OffCheck Box151: OffCheck Box152: OffCheck Box153: OffText155: Text156: Text157: Text158: Text159: Text160: Check Box161: OffCheck Box162: OffCheck Box163: OffCheck Box164: Offother minor andor dependent children: Text45: Text61: