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Domestic Relations Affidavit

In the case of spouses involved in a divorce case wanting to allow the court to determine each of their financial obligations, the following form affidavit has to be carried out by both spouses.

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Rev. 07/09 by KSJC 	1 of 6	
Domestic Relations Affidavit 	
 
 
IN THE       	
 JUDICIAL DISTRICT 
   	
 COUNTY, KANSAS 
 
 
IN THE MATTER OF        ) 
      ) 
      	
 ) 
       ) 
       ) 
 and      )    Case No.   	
 
       ) 
       ) 
      	
 ) 
       ) 
 
DOMESTIC RELATIONS AFFIDAVIT OF         	
 
        (name) 
 
1. Wife’s / Mother’s Residence         
 
 
  Wife’s / Mother’s     	
 XXX-XX- _______      	 
    Birth Month/Year Social Security Number  Telephone 
       
2. Husband’s  / Father’s Residence         
 
 
 Husband’s  / Father’s    	
 XXX-XX- _______      	 
    Birth Month/Year Social Security Number  Telephone 
       
3.  Date of Marriage:       	
 
 
4.  Number of Marriages:       
    	 
             Wife / Mother         Husband / Father  
 
5.  Number of children of the relationship:     	
 
 
6.  Names, Social Security Numbers, the month and year  of each child’s birth and ages of minor children of 
the relationship: 
 
      Name      Social Security Number  Birth    Age      Custodian 
              XXX-XX- _______  Month /Year 
 
     	
      	    	  	    	 
     	
      	    	  	    	 
     	
      	    	  	    	 
     	
      	    	  	    	 
 
7.  Names, Social Security Numbers, and ages of minor children of previous relationships and facts as to  custody and support payments paid or received, if any. 
 
            Social             Support       Paid 
Name              Security No.    Age       Custodian       Payment       or Rec’d 
                 XXX-XX- _______ 
     	
     	  	     	 $   	    	 
     	
     	  	     	 $   	    	 
     	
     	  	     	 $   	    	 
     	
     	  	     	 $

Rev. 07/09 by KSJC 	2 of 6
 
8.  Wife / Mother is employed by               	
 
 
                         
 
 
  Husband / Father is employed by              
 
 
                        
 
 
            (Name and address of employer) 
 
with monthly income as follows: 
 
A.  Wage Earner               Wife / Mother  Husband / Father 
 
 1. Gross Income     $   	
 $   	 
 2. Other Income     $   	
 $   	 
 3. Subtotal Gross Income    $   	
 $   	 
 4. Federal Withholding    $   	
 $   	 
  (Claiming _____ exemptions) 
 5. Federal Income Tax    $   	
 $   	 
 6. OASDHI     $   	
 $   	 
 7. Kansas Withholding    $   	
 $   	 
 8. Subtotal Deductions    $   	
 $   	 
 9. Net Income     $   	
 $   	 
 
B. Self-Employed         Wi fe / Mother    Husband / Father 
 
  1.  Gross Income from 
  self-employment    $   	
 $   	 
 2. Other Income     $   	
 $   	 
 3. Subtotal Gross Income    $   	
 $   	 
 4. Reasonable Business Expenses   $   	
 $   	 
    (Itemize on attached exhibit)        
 5. Self-Employment Tax    $   	
 $   	 
 6. Estimated Tax Payments   $   	
 $   	 
  (Claim _____ exemptions)   
 7. Federal Income Tax    $   	
 $   	 
 8. Kansas Withholding    $   	
 $   	 
 9. Subtotal Deductions    $   	
 $   	 
 10. Net Income     $   	
 $   	 
    (Line B.3. minus Line B.9.)       
 
Pay period:      	
           	 
           Wife / Mother          Husband / Father  
 
9.  The liquid assets of the parties are: 
           Joint or Individual 
   Item    Amount    (Specify) 
 
  A.  Checking Accounts (Do not list account numbers): 
     	
  $     	    	 
     	
  $     	    	 
  B.  Savings Accounts (Do not  list account numbers): 
     	
  $     	    	 
     	
  $     	    	 
 C. Cash 
   Wife / Mother    $   	
    	 
   Husband / Father   $

Rev. 07/09 by KSJC 	3 of 6
 D. Other 
     	
  $     	    	 
     	
  $     	    	 
 
10.  The monthly expenses of each party  are:  (Please indicate with an asterisk all figures which are 
estimates rather than actual figures taken from records.) 
 
  A.                Wife / Mother   Husband / Father  
      Item          (Actual or  Estimated)     (Actual or Estimated) 	
 
    1.  Rent (if applicable)*     $    	  $    	 
    2.  Food        $    	
  $    	 
  3. Utilities /services: 
       Trash Service     $    	
  $    	 
       Newspaper      $    	
  $    	 
       Telephone      $    	
  $    	 
    Mobile Phone      $    	
  $    	 
     Cable       $    	
  $    	 
    Gas      $    	
  $    	 
       Water       $    	
  $    	 
       Lights       $    	
  $    	 
       Other       $    	
  $    	 
  4. Insurance: 
    Life      $    	
  $    	 
       Health       $    	
  $    	 
    Car      $    	
  $    	 
       House/Rental     $    	
  $    	 
       Other       $    	
  $    	 
    5.  Medical and dental     $    	
  $    	 
    6.  Prescriptions drugs     $    	
  $    	 
    7.  Child care (work-related)   $    	
  $    	 
    8.  Child care (non-work-related)  $    	
  $    	 
    9.  Clothing       $    	
  $    	 
    10.  School expenses     $    	
  $    	 
    11.  Hair cuts and beauty    $    	
  $    	 
    12.  Car repair       $    	
  $    	 
    13.  Gas and oil       $    	
  $    	 
    14.  Personal property tax    $    	
  $    	 
 
                  Wife / Mother   Husband / Father 
      Item           (Actual or Estimated)    (Actual or Estimated) 
   15. Miscellaneous (Specify) 
        	
 $    	  $    	 
        	
 $    	  $    	 
        	
 $    	  $    	 
        	
 $    	  $    	 
 
 
  16. Debt Payments (Specify) 
 
        	
 $    	  $    	 
        	
 $    	  $    	 
        	
 $    	  $    	 
        	
 $    	  $    	 
 
    Total     $    	
  $    	 
 
  *Show house payments, mortgage pay ments, etc., in Section 10.B.

Rev. 07/09 by KSJC 	4 of 6
 
  B.  Monthly payments to banks, loan companies or on credit accounts:  (Indicate actual or 
estimated monetary amount in each column, use asterisk for secured.)  DO NOT LIST ANY 
PAYMENTS INCLUDED  IN PART 10.A ABOVE. 
 
       When  Amount of      Date of       Responsibility 
 Creditor   Incurred  Payment  Last Payment  Ba lance     Wife / Mother   Husband / Father
                              (Amount)        (Amount) 
     	
    	     	     	$     	$    	$    	 
     	
    	     	     	$     	$    	$    	 	
     	    	     	     	$     	$    	$    	 	
     	    	     	     	$     	$    	$    	 	
     	    	     	     	$     	$    	$    	 	
     	    	     	     	$     	$    	$    	 
            	
Subtotal of Payments  $    	$    	 
            Total      $    	
$    	 
 
  C.  Total Living Expenses 
                 Wife / Mother    Husband / Father 
                              (Actual or Estimated)           (Actual or Estimated) 	
 
    1. Total funds available to    $    	   $    	 
      Wife / Mother and Husband / Father                    
      (from No. 8)       
    2. Total needed       $    	
   $    	 
      (from No. 10.A and B)    
    3. Net Balance      $    	
   $    	 
    4. Projected child support    $    	
   $    	 
 
    D.  Payments or contributions received, or paid,  for support of others.  Specify source and amount. 
 
    Source        Wife / Mother              Husband / Father  
    	
(+/-)  $    	  $   	 
    	
(+/-)  $    	  $   	 
    	
(+/-)  $    	  $   	 
    	
(+/-)  $    	  $   	 
 
11.  How much does the party who provides health care pay for family coverage? 
 $  	
per   	. 
  How much does it cost the provider to  furnish health insurance only on the provider? 
 $  	
per   	. 
 
 
FURNISH THE FOLLOWING IN FORMATION IF APPLICABLE. 
 
12.  Income and financial resources of children. 
 
  Income/Resources           Amount 
              	
        $   	 
              	
        $   	 
              	
        $   	 
              	
        $   	 
 
13.    Child support adjustments requested. 
 
                Wife / Mother   Husband / Father 
 
  Long Distance Parenting Time  Costs     $    	
  $   	 
                $    	
  $

Rev. 07/09 by KSJC 	5 of 6
  Parenting Time
 Adjustments        $    	
  $   	 
  Income Tax Considerations        $    	
  $   	 
  Special Needs           $    	
  $   	 
  Support Beyond Age of Majority       $    	
  $   	 
  Overall Financial Condition        $    	
  $   	 
 
14.  All other personal property includi ng retirement benefits (including but not limited to qualified plans such as 
profit-sharing, pension, IRA, 401(k),  or other savings-type employee benefits, nonqualified plans, and deferred 
income plans), and ownership thereof (joint or individual),  including policies of insurance, identified as to nature 
or description, ownership (joint or individual), and actual or estimated value. 
                  Joint or Individual 
         Amount   (Specify) 
      	
  $  	   	 
      	
  $  	   	 
      	
  $  	   	 
      	
  $  	   	 
 
 
  THE FOLLOWING NEED NO T BE FURNISHED IN POST JUDGMENT PROCEDURES. 
 
15.  List real property identified as to description, ow nership (joint or individual) and actual or estimated 
value. 
 
 Property Description   Ownership   Actual/Estimated Value 
             
 
             
 
             
 
             	
            
            
            	 
 
16.  Identify the property, if any, ac quired by each of the parties prior to marriage or acquired during 
marriage by a will or inheritance. 
 
        Source of   Actual/ 
 Property Description  Ownershi p   Ownership  Estimated Value 
             
 
             
 
             
 
             	
            
            
            	 
 
17.  List debt obligations, including maintenance, not listed in Section 10.A or 10.B above, identified as to 
name or names of obligor or obligors and obligees, balance due and rate at which payable; and, if 
secured, identify t he encumbered property. 
 
 Debt              Balance Payment  Encumbered 
Obligation    Obligor   Obligee     Due     Rate    Property

Rev. 07/09 by KSJC 	6 of 6
18.  List health insurance coverage and the ri
ght, pursuant to ERISA §§ 601-608, 29 U.S.C.  
§§ 1161-1168 (1986), to continued coverage by the spouse who is not a member of the  
covered employee group. 
 
  Health Insurance	
               COBRA Continuation	 
        Yes    No   Unknown 
       	
    	       	    	 
       	
    	       	    	 
       	
    	       	    	 
       	
    	       	    	 
       	
    	       	    	 
       	
    	       	    	 
 
 
    AFFIANT	
 
 
    /s/   	
 
  VERIFICATION	
 
 
 
 State of      	
, County of    	, 
  
I swear or affirm under penalty of perjury that  this affidavit and attached schedules are true and 
complete. 
 
/s/    	
 
 
Subscribed and sworn this  
 day of       	, 20  	. 
 
 
    /s/      	
 
    Notary Public 
 
      My Appointment Expires: ____________________________
Next: Decree of Dissolution of Marriage Previous: Declaration of Disclosure of Assets, Debts, Income, and Expenses
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