Affidavit of Financial Information — Property & Finances

a. General Information

Name Write the full name of one person who lives with you.

b. Children's Basic Information

Date of Birth Write the day, month, and year this person was born. Relationship to you Write how this person is related to you, such as spouse, child, or roommate. Income Write how much money this person earns each month before taxes. Write none if they have no income. Name Write the full name of another person who lives with you. Date of Birth Write the day, month, and year this person was born. Relationship to you Write how this person is related to you, such as spouse, child, or roommate. Income Write how much money this person earns each month before taxes. Write none if they have no income. H. Attorney's Fees paid in this matter $ Write the dollar amount you have paid your lawyer for this case. Source of funds Tell where the money came from to pay your lawyer, like savings or a loan. A. Your job/occupation/profession/title: Write your job title or the kind of work you do. Name and address of current employer: Write the name of the place you work and its full street address. Date employment began: Write the date you started this job. Weekly Check this box if you get paid once a week. Every other week Check this box if you get paid every two weeks. Monthly Check this box if you get paid once a month. Twice a month Check this box if you get paid two times a month. Other Check this box if you get paid on a different schedule. Other Explain how often you get paid if it is not one of the choices above. B. If you are not working, why not? If you do not have a job, explain why you are not working. C. Previous employer name and address: Write the name and full address of the place you used to work. Previous job/occupation/profession/title: Write the job title or kind of work you did at your last job. Date previous job began: Write the date you started your last job. Date previous job ended: Write the date your last job ended. Reason you left job: Explain why you stopped working at your last job. Gross monthly pay at previous job: $ Write how much you earned each month before taxes at your last job. Year Write the first of the last three tax years you are reporting. $ Write your total income before taxes for that year from your tax return. Year Write the second of the last three tax years you are reporting. $ Write your total income before taxes for that year from your tax return. Year Write the third of the last three tax years you are reporting. $ Write your total income before taxes for that year from your tax return. E. Your total gross income from January 1 of this year to the date of this Affidavit (year-to-date income): $ Write all the money you have earned before taxes since January 1 of this year up to today. A. Gross salary/wages per month $ Enter your total pay each month before any taxes or deductions are taken out. Rate of Pay $ Enter the dollar amount you are paid, then check the box that shows the time period it covers. [ ] hour Check this box if your pay rate is for each hour you work. [ ] week Check this box if your pay rate is for each week you work. [ ] month Check this box if your pay rate is for each month you work. [ ] year Check this box if your pay rate is your yearly salary. 1. Automobile $ Enter the monthly value of a car your employer pays for. Enter 0 if none. 2. Auto expenses, such as gas, repairs, insurance $ Enter the monthly amount your employer pays for gas, repairs, or car insurance. Enter 0 if none. 3. Lodging $ Enter the monthly value of housing or lodging your employer pays for. Enter 0 if none. 4. Other (Explain) Describe any other expense your employer pays for you that wasn't listed above. 4. Other (Explain) $ Enter the monthly dollar amount of the other employer-paid expense you described. C. Commissions/Bonuses $ Enter your average monthly income from commissions or bonuses. Enter 0 if none. D. Tips $ Enter your average monthly income from tips. Enter 0 if none. E. Self-employment Income (See below) $ Enter your average monthly income from your own business or self-employment. Enter 0 if none. F. Social Security benefits $ Enter the monthly amount you get from Social Security. Enter 0 if none. G. Worker's compensation and/or disability income $ Enter the monthly amount you get from worker's compensation or disability. Enter 0 if none. H. Unemployment compensation $ Enter the monthly amount you get in unemployment benefits. Enter 0 if none. I. Gifts/Prizes $ Enter the average monthly value of gifts or prizes you receive. Enter 0 if none. J. Payments from prior spouse Enter the monthly amount you get from a former husband or wife, like alimony or spousal support. K. Rental income (net after expenses) Enter the monthly money you make from renting out property after you subtract your costs. L. Contributions to household living expense by others Enter the monthly amount others give you to help pay for your home and living costs. M. Other (Explain:) Describe any other income not listed above, such as dividends, pensions, interest, or royalties. M. Other (Explain:) $ Enter the monthly dollar amount for the other income you just described. TOTAL: $ Add up all the income amounts on this page and write the total here. Name, address and telephone no. of business: Write the name, full address, and phone number of the business you own or run. Type of business entity: Tell what kind of business it is, such as sole owner, partnership, LLC, or corporation. State and Date of incorporation: Enter the state where the business was formed and the date it became official. Nature of your interest: Explain your role in the business, such as owner, partner, or shareholder. Nature of business: Describe what the business does or what it sells. Percent ownership: Enter the percent of the business that you own, like 50% or 100%. Number of shares of stock: If the business has stock, write how many shares you own. Total issued and outstanding shares: Write the total number of shares the business has given out to all owners. Gross sales/revenue last 12 months: Enter all the money the business took in over the past 12 months before any costs.

c. Health & Medical Support

Drugs and medical supplies Enter how much you pay each month for medicine and medical supplies after any insurance pays its share. Other Describe any other medical or dental costs you pay that are not covered by insurance. Other Enter the monthly dollar amount for those other medical or dental costs. TOTAL: Add up the amounts above and write the total here. Total monthly child care costs Enter the total you pay each month for child care. Do not include money paid by D.E.S. Name(s) of child(ren) cared for and amount per child: Enter the monthly child care cost for this child. Name(s) of child(ren) cared for and amount per child: Enter the monthly child care cost for this child. Name(s) of child(ren) cared for and amount per child: Enter the monthly child care cost for this child. YES Check this box if your job lets you pay for child care with money taken out before taxes. NO Check this box if you do not use a pretax plan at work for child care.

d. Child Support

Court ordered current child support for child(ren) not common to the parties Enter how much child support you must pay each month for children who are not shared with the other party in this case.

e. Health & Medical Support

Court ordered cash medical support for child(ren) not common to the parties Enter the monthly cash medical support you must pay for children not shared with the other party in this case. Amount of any arrears payment Enter the monthly amount you pay toward past-due support you still owe. Amount per month actually paid in last 12 mos. Enter the average amount you actually paid each month over the last year. Attach proof that you are paying. Court ordered spousal maintenance/support you actually pay to previous spouse: Enter the monthly dollar amount you actually pay to a former husband or wife because a court ordered you to. For Children (Educational Expense/Special Needs/Other): Enter the monthly dollar amount you spend on unusual costs for the children, like special schooling or medical needs. Explain: Describe what the unusual children's expense is for, such as private school tuition or therapy. For Self: Enter the monthly dollar amount you spend on unusual costs for yourself. Explain: Describe what your unusual personal expense is for, such as ongoing medical treatment. First Mortgage Enter what you pay each month for your first home loan. Second Mortgage Enter what you pay each month for a second home loan, if you have one. Homeowners Association Fee Enter the monthly fee you pay to your homeowners association, if any. Rent Enter how much rent you pay each month if you rent your home. Repair & upkeep Enter what you spend each month to fix and maintain your home. Yard work/Pool/Pest Control Enter your monthly cost for yard care, pool service, or pest control. Insurance & taxes not included in house payment Enter monthly home insurance and property taxes only if they are not already in your house payment. Other (Explain): Describe any other monthly housing cost not listed above. Other (Explain): $ Enter the monthly dollar amount for the other housing cost you described. TOTAL: Add up all the housing amounts above and write the total here. Water, sewer, and garbage Enter your monthly cost for water, sewer, and trash pickup. Electricity Enter how much you pay each month for electricity. Gas Enter how much you pay each month for gas service. Telephone Enter your monthly cost for home phone service. Mobile phone/pager Enter how much you pay each month for your cell phone or pager. Internet Provider Enter your monthly cost for internet service. Cable/Satellite television Enter how much you pay each month for cable or satellite TV. Other (Explain): Describe any other monthly utility cost not listed above. Other (Explain): $ Enter the monthly dollar amount for the other utility you described. TOTAL: Add up all the utility amounts above and write the total here. Food, milk, and household supplies Enter what you spend each month on groceries and household supplies. School lunches Enter your monthly cost for school lunches. Meals outside home Enter how much you spend each month eating out or on takeout. TOTAL: Add up all the food amounts above and write the total here. Clothing for you Enter how much you spend each month on clothes for yourself. Uniforms or special work clothes Enter your monthly cost for uniforms or special clothes needed for your job. Clothing for children living with you Enter how much you spend each month on clothes for the children who live with you. Laundry and cleaning Enter your monthly cost for washing clothes or dry cleaning. TOTAL: Add up all the clothing costs above and write the total here. Car insurance Enter how much you pay each month for car insurance. List all cars and individuals covered: List each car and the people covered by your car insurance. Car payment, if any Enter your monthly car loan or lease payment, if you have one. Car repair and maintenance Enter how much you spend each month on car repairs and upkeep. Gas and oil Enter your monthly cost for gas and oil for your car. Bus fare/parking fees Enter your monthly cost for bus fares or parking fees. Other (explain): Describe any other travel cost you have that is not listed above. Other (explain): Enter the monthly amount for the other travel cost you described. TOTAL: Add up all the travel and car costs above and write the total here. School and school supplies Enter your monthly cost for school and school supplies. School activities or fees Enter your monthly cost for school activities or fees. Extracurricular activities of child(ren) Enter your monthly cost for the children's activities outside of school, like sports or clubs. Church/contributions Enter how much you give each month to your church or other groups. Newspapers, magazines and books Enter your monthly cost for newspapers, magazines, and books. Barber and beauty shop Enter your monthly cost for haircuts and beauty shop visits. Life insurance (beneficiary: Write the name of the person who would get the money from your life insurance. Life insurance (beneficiary: Enter how much you pay each month for life insurance. Disability insurance Enter your monthly cost for disability insurance. 9. Recreation/entertainment Enter how much you spend each month on fun activities like movies, hobbies, or sports. 10. Child(ren)'s allowance(s) Enter the monthly amount you give your children as spending money. 11. Union/Professional dues Enter the monthly cost of any union or professional group fees you must pay for your job. 12. Voluntary retirement contributions and savings deductions Enter the monthly amount you choose to put into retirement or savings accounts. 13. Family gifts Enter how much you spend each month on gifts for family members. 14. Pet Expenses Enter your monthly cost for pets, like food, supplies, and vet care. 15. Cigarettes Enter how much you spend each month on cigarettes or other tobacco. 16. Alcohol Enter how much you spend each month on alcohol. 17. Other (explain): Describe any other monthly expense not already listed above. 17. Other (explain): Enter the monthly dollar amount for the other expense you described. TOTAL: Add up all the expense amounts above and write the total here. Creditor Name Write the name of the person or company you owe money to. Purpose of Debt Explain what the debt was for, such as a car loan or credit card. Unpaid Balance Enter how much you still owe on this debt. Min. Monthly Payment Enter the smallest amount you must pay each month on this debt. Date of Your Last Payment Enter the date you last made a payment on this debt. Amount of Your Payment Enter the dollar amount of your last payment on this debt.