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Georgia Domestic Relations Financial Affidavit Form

Through the fulfillment of this form, both divorcing spouses will be able to learn about the financial situation of each other.Download

Extracted Text for Proper Search

Domes
tic Rela tions Fi nancial Affi davit - rev.  DR AFT January 8, 2007 Page 1 of 6                            COUNTY SUPERIOR COURT
STATE  OF G EORGIA
                                                                        \
       ,
Plaintiff,
vs.
                                                                        \
       ,
Defend ant. Civil Action
Case Number
                                                         DO
ME STIC  RELATIO NS FINANCIAL A FFIDAVIT
(1)   Your Name: Your Age:
Spouse’s Name: Spouse’s Age:
Date of Marriage: Date of Separation:
Names and birth dates of children for whom support is to be determined i\
n this action: Name Date of Birth Resides with
Names and birth dates of y our other children:
Name Date of Birth Resides with
(2)  SUMMARY OF  YOUR  INCOME AND  NEEDS :    (fill out this part after y ou complete pages 2-5)
(A) Gross Monthly I ncome (from Item 3A be low) $                   
(B) Net Monthly  Income (from Item 3B be low) $                   
(C) Aver age Monthly Expenses  (Item 5A below) $                   
Monthly  Payments to Cr editors (Item 5B below) $                   
Total Monthly Expenses & Pay ments to Creditors (Item 5C below) $

Domes
tic Rela tions Fi nancial Affi davit - rev.  DR AFT January 8, 2007 Page 2 of 6 (3) (A) 
YOUR  GROSS  MONTHLY  INCOME :(Complete this s ection or  attach Child Support Schedule A.  
All income must be entered based on monthly average regardless of date o\
f rece ipt.  
Where applicable, income should be annualized.)
Salary or Wag es  — ATTACH COP IES OF 2 MOST  RECENT WAGE STATEMEN TS $                   
Commissions, Fees & Tips $             
Inc ome from s elf-employment, par tnership, close c orporations and in dependent contra cts
(gross receipts minu s ordinary and necessa ry expenses required to  produce income)
 ATTACH SHEET ITEMIZING  YOUR CALCULATIONS $              
Rental income    (gross receipts m inus ordinary and nece ssary expenses required to  produce
income) ATTACH SHEET ITEMIZING  YOUR CALCULATI ONS$              
Bonuses $             
Overtime  Payments $             
Severance Pay $             
Recurring I ncome from Pensions or Retirement Plans $             
Interest and Dividends $             
Trust inc ome $             
Income from Annuities $             
Capital Gains $             
Social Sec urity Disability  or Retirement Ben efits $             
Worker’ s Compensa tion Benefits $             
Unemploy ment Benefits $             
Judgments from Personal Injury  or Other Civil Cases $             
Gifts (cash or other gifts that can be c onverted to cash) $             
Priz es & Lott ery Winni ngs $             
Alimony  and maint enance from per sons not in t his case $             
Assets wh ich are used for  support of  family $             
Fring e Bene fits (if si gnificantly reduce  living e xpenses) $             
Any  Other I ncome (Do not include  means-tested public assistanc e, such as TANF or food stamps.) $              
TOTAL Gross Monthly Income    (also write in 2A on page one) $                  
(3)(B) N et Monthl y Income From Employm ent (deducting only state  and federal taxes and
FICA)    (also write in 2B on page one) $

Domes
tic Rela tions Fi nancial Affi davit - rev.  DR AFT January 8, 2007 Page 3 of 6 Your Pay Period (
i.e., monthly, weekly , etc .): Number of Exemptions Claimed
by You for Ta x Purposes:
(4)  ASSETS
(List all a ssets here, including both non -marital and marital p roperty.  If you cl aim or agre e that all
or part of an asset is non-marital, indicate the non-marital portion und\
er the appropriate spouse’s
column and state the amount and the basis: pre-marital, gift, inheritanc\
e, source of funds, etc.  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.)
Description ValueSeparate
Asset of
Husband Separate
Asset of Wife Basis of
 the Claim
(pre- marital, gi ft,
inheritance, etc.)
Cash $             $                    $                  
Stocks, Bonds $               $                 $                
CD’s / Mone y Market Acc ounts $               $                 $                
Bank Ac counts (list each acco unt below) :                                                 
(1) $               $                $               
(2) $               $                 $                
(3) $               $                 $                
Retirement Pensions, 401(k), IRA or Profit-Sharing $               
$                 $                
Money Owed to You ( or Spouse)$               $                 $                
Tax Refund Owed to You $               $                 $                
Real Estate (list properties & mortgag es):
       Home $               $                 $                
Debt owe d on Home $               
       Other Re al Estate $               $                 $                
Debt owe d on Other  Real Estate$                               
Automobile s / Vehicles (list vehicles & amounts ow ed on each one): 
       (1) $               $                 $                
Debt owed on Vehicle (1) $               
       (2) $               $                 $                
Debt owed on Vehicle (2) $

Domes
tic Rela tions Fi nancial Affi davit - rev.  DR AFT January 8, 2007 Page 4 of 6 (4) 
ASSETS    (continued)
Description ValueSeparate
Asset of
Husband Separate
Asset of Wife Basis of the C
laim
(pre- marital, gi ft,
inheritance, etc.)
Life I nsurance (net cash value) $               $                 $                
Furni ture / Furni shings $               $                 $                
Jewelry $               $                 $                
Collectibles $               $                 $                
Other As sets (specify) : $               $                 $                
$                $                 $                
$                $                 $                
TOTAL ASSETS $                
$                    $                  
(5)(A)     A VERAGE  MONTHLY  EXPENSE S FOR YOU AND  YOUR  HOUSEHOLD
HOUSEHOLD EXP ENSES
Mortga ge or Re nt Payments $               Gas $               
Property taxes $               Repairs & Maintenance $               
Homeowner’s / Renter’s I nsurance$               Lawn Care $               
Electric ity $               Pest Control $               
Water $               Cable TV / Internet Acc ess $               
Garbage & Sewer $               Misc. Household & Grocery Items $               
Telephones Meals Outside Home $               
Residential Lines $              Other (specify) $               
Cellular Telephones $               $               
AUTOMOTIVE
Gasoline  & Oil $               Auto Tags / Registration / License $               
Repairs & Maintenance $               Insurance $               
OTHER VEHICLES (boats, trailers, RVs, etc.)
Gasoline  & Oil $               Tags / Registration / L icense $               
Repairs & Maintenance $               Insurance $

Domes
tic Rela tions Fi nancial Affi davit - rev.  DR AFT January 8, 2007 Page 5 of 6 CHILDREN’
S EXPENSES
Child Care  (total mon thly cost) $               Allowance $               
School Tuition $               Children’s Clothing $               
Tutoring $               Diapers $               
Private le ssons (e.g., music,  dance)
$               Medical
, Dental,  Prescriptions 
        (out-of-pocket uncovered  expenses)$               
School Supplies / Expenses $               Grooming / Hyg iene $               
Lunch Money $               Gifts from children to others $               
Other Educational Expenses (list type &  amount):Entertainment $               
______________________ $               Activitie
s (including extra-curricular ,
school, religious, cultural,  etc.)$               
______________________ $               Summer Camps $               
OTHER INSURANCE
Health Insurance $               Life Insurance $               
Children’s portion: $                      Relati ons hip of Be neficiary:
Dental Insurance $               Disability Insurance $               
Children’s portion: $               Other Insurance  (specify) $               
Vision Insurance $                $               
Children’s portion: $                $               
YOUR OTHER E XPENSES
Dry Cleaning  & Laundry $               Publications $               
Clothing $               Dues, Clubs $               
Medical / Dental / Prescription  (out-of-pocket uncovered  expenses)$               
Religious & Charities $               
Your Gif ts (special holida ys) $               Pet expenses $               
Entertainment $               Alimony Paid to Fo rmer Spouse $               
Recrea tional Expe nses (e.g., fi tness) $               Child Support Paid for other children $               
Vacations $                     Date of initial CS order:
Travel Expenses for Visitation $               Other  (attach sheet to  list) $               
TOTAL ABOVE M ONTHLY EXPENSES (also write on first line of 2C on page one)
$

Domes
tic Rela tions Fi nancial Affi davit - rev.  DR AFT January 8, 2007 Page 6 of 6 (5)(B)
YOUR  PAYMENTS  & D EBTS T O CREDIT ORS
To Whom Balance DueMonthly
Pay ments (Please check one)
Joint Husband
Wife
$ $             
$ $             
$ $             
$ $             
$ $             
$ $             
Total Monthly Payments to Creditors   (also write this total o n line 2 of 2C on page one)
$                  
(5)(C) TOTAL MONTHL Y EXPENSES 
(Total Expenses fro m final line on page  5 + Total Monthly Paym ents to Creditors above)
(also write this total o n line 3 of 2C on page one) $                  
Subscribed and sworn before me on
                                               , 20
           .
                                                                   Notary
 Public                                                                         \
                              
G  Plaintiff    G Defend ant       Pro se
(Sign in front of n otary public.)
Name:                                                                          \
               Address
:                                                                         \
                                                                                    \
                         
Day
time Phone :   (                 )                                                 \
 pro se DR $ A
ffidavit for new USCR24 approve d corrected 2.wpd
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