Affidavit of Income (Dissolutions Only)

In the case of a divorce, the following affidavit has to be executed in order to disclose the income of the involved parties with the court.

Extracted Text for Proper Search

J-424    Page 1 of  2 
 	
 	
IN THE FRANKLIN COUNTY COURT OF COMMON PLEAS  
DIVISION OF DOMESTIC RELATION S AND JUVENILE BRANCH  	
 
 
 	 	Case No.  	
Petitioner	 	 	Judge	 	 	
and 	 	Magistrate	 	 	
 	 	 	
Petitioner  	 	 	
Instructions	:  This affidavit is required to be filed 	by the parties 	upon the filing of a	 Petition for Dissolution pursuant 	
to Local Domestic Rule 17.    This affidavit is for complete disclosure of  income  by the parties .  Do not leave any category 
blank.  Write “none” where appropriate.  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 INCOME 	 	
Affidavit of	 	 	 	
 	(Print Your Name)	 	 	
 	
 	Date of marriage	 	 	Date of separation	 	 	 	 
 	Husband	 	Wife	 	
Employed	 	 Yes	 	 No	 	 Yes	 	 No	 	
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	 	
 	Husband	 	 	Wife	 	
Base yearly income 	
$ 	 	3 years ago    	 20	 	 	$ 	 	
$ 	 	2 years ago	 	20	 	 	$ 	 	
$ 	 	Last year     	 	20	 	 	$ 	 	
 
Yearly overtime, commiss ions 
and/or bonuses  	
$ 	 	3 years ago    	 20	 	 	$ 	 	
$ 	 	2 years ago	 	20	 	 	$ 	 	
$ 	 	Last year     	 	20	 	 	$ 	 	
 
B.  COMPUTATION OF CURRENT INCOME	 	
 	Husband	 	Wife	 	
 
Base yearly income	 	$  	$  	
Average yearly overtime, 
commissions and/or bonuses 
over last 3 years (from part A	) 	$  	$  	
 
Unemployment compensation	 	$  	$

J-424    Page 2 of  2 
 	
 	
 
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 ass	istance	 	$  	$  	
 
 
 
 
 
 
 
O ATH  
( Do not sign until notary is present.)  	
I, (print name)	 	
 	
, swear or affirm that I have read	 	
this 	document	 and, to the best of my knowledge and belief, the facts and information stated in this document 	
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	 	
 
Sworn before me and signed in my presence this	 	 	day of	 	 	, 	 	. 	
   
 	Notary Public	 	
 	My Commission  Expires: