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
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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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