In the Superior Court of ______________ County, Georgia
)
______________________, Plaintiff )
)
vs. ) Civil Action No. ___________
)
______________________, Defendant )
)
DOMESTIC RELATIONS FINANCIAL AFFIDAVIT
1. AFFIANT’S NAME:______________________________ Age _________
Spouse’s Name: _______________________________ Age _________
Date of Marriage: _____________________ Date of Separation __________________
Names and birth dates of children for whom support is to be determined in this action:
Name Date of Birth Resides with
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Names and birth dates of affiant’s other children:
Name Date of Birth Resides with
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
2. SUMMARY OF AFFIANT’S INCOME AND NEEDS
(a) Gross monthly income (from item 3A) $ ______________
(b) Net monthly income (from item 3C) ______________
(c) Average monthly expenses (item 5A) $ ______________
Monthly payments to creditors + ______________
Total monthly expenses and payments
to creditors (item 5C) _______________
(subsections (d) & (e) deleted)
3
3. A. AFFIANT’S GROSS MONTHLY INCOME (complete this section or attach Child Support Schedule A)
(All income must be entered based on monthly average regardless of date of receipt.)
Salary or Wages $ ______________
ATTACH COPIES OF 2 MOST RECENT WAGE STATEMENTS
Commissions, Fees, Tips $ ______________
Income from self-employment, partnership, close corporations,
and independent contracts (gross receipts minus ordinary
and necessary expenses required to produce income)
ATTACH SHEET ITEMIZING YOUR CALCULATIONS $ ______________
Rental Income (gross receipts minus ordinary and
necessary expenses required to produce income)
ATTACH SHEET ITEMIZING YOUR CALCULATIONS $ ______________
Bonuses $ ______________
Overtime Payments $ ______________
Severance Pay $ ______________
Recurring Income from Pensions or Retirement Plans $ ______________
Interest and Dividends $ ______________
Trust Income $ ______________
Income from Annuities $ ______________
Capital Gains $ ______________
Social Security Disability or Retirement Benefits $ ______________
Workers’ Compensation Benefits $ ______________
Unemployment Benefits $ ______________
Judgments from Personal Injury or Other Civil Cases $ ______________
Gifts (cash or other gifts that can be converted to cash) $ ______________
Prizes/Lottery Winnings $ ______________
Alimony and maintenance from persons not in this case $ ______________
Assets which are used for support of family $ ______________
Fringe Benefits (if significantly reduce living expenses) $ ______________
Any other income (do NOT include means-tested
Public assistance, such as TANF or food stamps) $ ______________
GROSS MONTHLY INCOME $ ______________
4
(prior section B deleted)
B. Affiant’s Net Monthly Income from employment
(deducting only state and federal taxes and FICA) $ _______________
Affiant’s pay period (i.e., weekly, monthly, etc.) ___________________
Number of exemptions claimed ____________
4. ASSETS
(If you claim or agree that all or part of an asset is non-marital, indicate the non-marital portion under the
appropriate spouse’s column and state the amount and the basis: pre-marital, gift, inheritance, source of
funds, etc.).
Description Value Separate Asset Separate Asset Basis of the
of the Husband of the Wife Claim
Cash $____________ ______________ ______________ ____________________
Stocks, bonds $____________ ______________ ______________ ____________________
CD’s/Money Market $____________ ______________ ______________ ____________________
Accounts
Bank Accounts
(list each account):
_______________ $____________ ______________ ______________ ____________________
_______________ $____________ ______________ ______________ ____________________
_______________ $____________ ______________ ______________ ____________________
Retirement Pensions,
401K, IRA, or $____________ ______________ ______________ ____________________
Profit Sharing
Money owed you: $____________ ______________ ______________ ____________________
Tax Refund
owed you: $____________ ______________ ______________ ____________________
Real Estate:
home: $ ___________ _____________ _____________ ____________________
debt owed: $ ___________
other: $____________ ______________ ______________ ____________________
debt owed: $ ____________
Automobiles/Vehicles:
Vehicle 1: $____________ ______________ ______________ ____________________
5
debt owed : $ ___________
$____________ ______________ ______________ ____________________
Vehicle 2:
$____________
debt owed:
Life Insurance
(net cash value): $____________ ______________ ______________ ____________________
Furniture/furnishings: $____________ ______________ ______________ ____________________
Jewelry: $____________ ______________ ______________ ____________________
Collectibles: $____________ ______________ ______________ ____________________
Other Assets: $____________ ______________ ______________ ____________________
_______________ $____________ ______________ ______________ ____________________
_______________ $____________ ______________ ______________ ____________________
_______________ $____________ ______________ ______________ ____________________
Total Assets: $____________ ______________ ______________ ____________________
5. A. AVERAGE MONTHLY EXPENSES
HOUSEHOLD
Mortgage or rent payments $ __________ Cable TV $ __________
Property taxes $ __________ Misc. household and grocery
Items $ __________
Homeowner/Renter Insurance $ __________ Meals outside the home $ __________
Electricity $ __________ Other $ __________
Water $ __________ AUTOMOBILE
Gasoline and oil $ __________
Garbage and Sewer $ __________
Repairs $ __________
Telephone:
residential line: $ __________ Auto tags and license $ __________
cellular telephone: $ __________ Insurance $ __________
Gas $ __________ OTHER VEHICLES
(boats, trailers, RVs, etc.)
Gasoline and oil $__________
Repairs and maintenance: $ __________
Repairs $__________
Lawn Care $ __________
Tags and license $__________
Pest Control $ __________
Insurance $__________
6
CHILDREN’S EXPENSES AFFIANT’S OTHER EXPENSES
Child care (total monthly cost) $__________ Dry cleaning/laundry $__________
School tuition $__________ Clothing $__________
Tutoring $__________ Medical, dental, prescription
(out of pocket/uncovered expenses) $__________
Private lessons (e.g., music, dance) $__________
Affiant’s gifts (special holidays) $__________
School supplies/expenses $__________ Entertainment $__________
Lunch Money $__________ Recreational Expenses (e.g., $__________
fitness)
Other Educational Expenses (list) Vacations $__________
____________________ $__________ Travel Expenses for Visitation $__________
____________________ $__________ Publications $__________
Allowance $__________ Dues, clubs $__________
Clothing $__________ Religious and charities $__________
Diapers $__________ Pet expenses $__________
Medical, dental, prescription Alimony paid to former spouse $__________
(out of pocket/uncovered expenses) $__________
Child support paid for other
Grooming, hygiene $__________ children $__________
Gifts from children to others $__________ Date of initial order: __________
Entertainment $__________ Other (attach sheet) $__________
Activities (including extra-curricular, $__________
school, religious, cultural, etc.)
Summer Camps $__________
OTHER INSURANCE
Health $__________
Child(ren)’s portion: $__________
Dental $__________
Child(ren)’s portion: $__________
Vision $__________
Child(ren)’s portion: $__________
Life $__________
Relationship of Beneficiary: ____________
Disability $__________
Other(specify): $__________
7
TOTAL ABOVE EXPENSES $ _______________________
B. PAYMENTS TO CREDITORS
(please check one)
To Whom: Balance Due Monthly Joint Plaintiff Defendant
Payment
TOTAL MONTHLY PAYMENTS TO CREDITORS: $ ___________________
C. TOTAL MONTHLY EXPENSES: $ ______________________
This ______ day of _________________________________, 20_____.
_____________________________________ _____________________________________
Notary Public Affiant
