Domestic Relations Financial Affidavit

IN THE SUPERIOR COURT OF FULTON COUNTY

STATE OF GEORGIA

FAMILY DIVISION

___________________________, :

:

Petitioner, :

: CIVIL ACTION FILE

v. :

: NO. ________________

___________________________, :

:

Respondent. :

:

DOMESTIC RELATIONS FINANCIAL AFFIDAVIT

You are required to make to the Court, under oath, a FULL DISCLOSURE of your

income, net worth and financial condition on this form. Fill out each and every section

of this form. If something does not apply to your situation, write, “N/A”.

1. Your Name:________________________________ DOB ______________

Address:_______________________________________ County: ________________

City: _______________________ State: _____________ Zip Code: _______________

Spouse's Name:_____________________________ DOB ______________

Address: _______________________________________ County: ________________

City: _______________________ State: _____________ Zip Code: _______________

Date of Marriage:___________________________

Date of Separation:__________________________

Names and birth dates of children for whom support is to be determined in this action:

________________________________________________________________________

Names and birth dates of your other children who are living with you:

________________________________________________________________________

Names and birth dates of the children for which you are obligated to pay support by a

court order:

__________________________________________________________________________

____________________________________________________________________

2. EMPLOYMENT AND INCOME

Occupation: ________________________________________________________

Employed By: ________________________________________________________

Number of exemptions claimed: __________________________________________

Pay period (ie, weekly, monthly, etc.) _____________________________________

If you are employed, but expecting soon to become unemployed or change jobs, describe the

change you expect and why and how it will affect your income. If currently unemployed, describe

your efforts to find employment, how soon you expect to be employed, and the pay you expect to

receive:

________________________________________________________________________________

______________________________________________________________________

EXCEPT IN PROCEEDINGS FOR ADOPTION, ENFORCEMENT, CONTEMPT, AND

INJUNCTIONS FOR DOMESTIC OR REPEAT VIOLENCE, ALL OF THE FOLLOWING

MUST BE ATTACHED TO THE COPY OF THIS FINANCIAL AFFIDAVIT SERVED ON THE

OPPOSING PARTY. THE ATTACHMENTS SHALL NOT BE FILED WITH THE COURT:

Your three (3) most recent pay stubs, your three (3) most recent Federal and State tax returns, and

the most recent W-2 forms. If last year’s Federal income tax return has not yet been filed, attach

W-2s, 1099s, K-1s, and any other document to be attached to your tax return. If the attachments are

not made to the copy served on the opposing party, an explanation is required.

3. SUMMARY OF YOUR INCOME AND NEEDS

(a) Gross monthly income (from Item 4A) $ ____________

(b) Total income taxes paid on above income

(Incl. Fed., State and FICA) $ ____________

(c) Net monthly income (from Item 4C) $ ____________

(d) Expenses

Average monthly expenses (Item 5A) $ ____________

Monthly payments to creditors (Item 5B) $ ____________

TOTAL monthly expenses and payments to

creditors (Item 5C) $ ____________

Domestic Relations Financial Affidavit

Fulton County Family Division

4. YOUR MONTHLY INCOME

A. Gross Income

(All income whether earned or unearned, from any source, must be entered based

on monthly average regardless of date of receipt.

Salary or Wages $ ____________

Bonuses, Commissions, Allowances, Fees,

Overtime, Tips and similar payments (based

on past 12-month average or time of employment

if less than 1 year) $ ____________

Income from sources such as self-

employment, partnership, close corporations

and independent contracts (gross receipts minus

ordinary and necessary expenses required to

produce income) ATTACH SHEET ITEMIZING

YOUR CALCULATIONS. $ ______________

Severance Pay $ ______________

Disability/Unemployment/Worker's Compensation $ ______________

Recurring Income from Pension and Retirement Plans

or Annuity payments $ ______________

Social Security benefits $ ______________

Other public benefits (do NOT include means-tested

public assistance such as TANF or food stamps) $ ______________

$ ______________

Spousal or child support from people not in this case $ ______________

Interest and Dividends $ ______________

Rental income (gross receipts minus ordinary and

necessary expenses required to produce income)

ATTACH SHEET ITEMIZING YOUR CALCULATIONS $ ______________

Reimbursed expenses and In kind payments to the extent

they reduce personal living expenses $ ______________

Fringe Benefits (if significantly reduce living expenses) $ ______________

Income from Royalties, Trusts or Estates $ ______________

Capital Gains or Gains derived from dealing in property

(not including non-recurring gains) $ ______________

Prizes/Lottery Winnings $ ______________

Gifts (cash or other liquid assets or which can be

converted to cash) $ ______________

Judgments from Personal Injury or other civil cases

where cash is received on a recurring basis $ ______________

Assets used for support of family $ ______________

Other income of a recurring nature (specify source) $ ______________

Gross Monthly Income $ ______________

Domestic Relations Financial Affidavit

Fulton County Family Division

B. Benefits of Employment

List and describe (where requested below) all benefits of employment not deducted

from your wages or salary. These are defined as those costs paid directly by your employer

on your behalf. Most, if not all, of these benefits are listed below. If a benefit(s) is not

listed, fill in “other” and, describe the benefit in the space provided.

Automobile

Payment $ ______________

Allowance $ ______________

Gasoline $ ______________

Insurance $ ______________

Other (Describe)

__________________________________________ $ ______________

Medical/Dental Expenses $ ______________

Insurance

Health $ ______________

Life $ ______________

Disability $ ______________

Other (Describe)

__________________________________________ $ ______________

Deferred Compensation (Describe)

__________________________________________ $ ______________

Employer Contribution to Retirement or Stock $ ______________

Club Membership $ ______________

Reimbursement Expenses (to the extent they reduce personal

living expenses and are not included in 4A) (Describe)

__________________________________________ $ ______________

OTHER (Describe)

________________________________________________ $ ______________

TOTAL $ ______________

C. Net Income

Net monthly income from employment (deducting only state and,

federal taxes, FICA, and self-employment tax, if applicable) $ ______________

5. YOUR NEEDS

A. AVERAGE MONTHLY EXPENSES

HOUSEHOLD

Residence

1

st

Mortgage $ ______________

2

nd

Mortgage $ ______________

Domestic Relations Financial Affidavit

Fulton County Family Division

Equity line of credit $ ______________

Other $ ______________

Property taxes $ ______________

Rent Payments $ ______________

Homeowner/Renter Insurance $ ______________

Condo, maintenance fees/homeowners association fees $ ______________

Electricity $ ______________

Water $ ______________

Gas $ ______________

Garbage and Sewer $

Telephone $ ______________

Cellular Telephone $ ______________

Repairs and Maintenance $ ______________

Lawn care $ ______________

Pool care $ ______________

Pest control $ ______________

Cable television $ ______________

Burglar alarm/security system $ ______________

Miscellaneous household and grocery items $ ______________

Meals outside home $ ______________

Meals outside home

$ ______________

Pets: grooming $ ______________

veterinarian $ ______________

food $ ______________

Drugstore items $ ______________

Service contracts on appliances $ ______________

Domestic help $ ______________

Internet $ ______________

Other (Attach sheet) $ ______________

AUTOMOBILE

Gasoline and Oil $ ______________

Repairs $ ______________

Auto tags and License $ ______________

Insurance $ ______________

Alternative transportation (bus, public

transportation, etc.) $ ________________

Tolls and parking $ ________________

OTHER VEHICLES, BOATS, TRAILERS

Gasoline and Oil $ ________________

Repairs $ ________________

Tags and License $ ________________

Domestic Relations Financial Affidavit

Fulton County Family Division

Insurance $ ________________

Other (Attach sheet) $ ________________

OTHER EXPENSES

Life Insurance $ ________________

Disability Insurance $ ________________

Dry cleaning and laundry $ ________________

Grooming $ ________________

Clothing $ ________________

Medical/dental (out of pocket/uncovered expenses) $ ________________

Prescriptions (out of pocket/uncovered expenses) $ ________________

Gifts (special holidays) $ ________________

Entertainment $ ________________

Vacations $ ________________

Travel expenses necessary for parenting time/visitation $ ________________

Retirement/401-K Contributions $ ________________

Publications $ ________________

School alumni dues $ ________________

Union dues $ ________________

Club membership dues and expenses $ ________________

Religious and charities $ ________________

Professional expenses (other than this proceeding) $ ________________

Bank charges/credit card fees $ ________________

Miscellaneous (attach sheet) $ ________________

Other (attach sheet) $ ________________

Alimony paid to former spouse(s) $ ________________

Child support paid for other children $ ________________

(Date of initial order: ___________________

County and State: __________________

Case number: __________________)

CHILDREN'S EXPENSES (Per child)

NAME NAME NAME NAME

__________ __________ _________ _________

Child care- school year $_________ __________ _________ _________

Child care- summer $_________ __________ _________ _________

School tuition $_________ __________ _________ _________

School uniform $_________ __________ _________ _________

Other school expenses $_________ __________ _________ _________

Private lessons (e.g. music,

dance, etc) $_________ __________ _________ _________

Tutoring $_________ __________ _________ _________

Lunch money $_________ __________ _________ _________

Domestic Relations Financial Affidavit

Fulton County Family Division

Allowances $_________ __________ _________ _________

Clothing $_________ __________ _________ _________

Cellular telephone $_________ __________ _________ _________

Medical/dental (out of pocket/

uncovered expenses $_________ __________ _________ _________

Psychiatric/psychological/

counseling (out of pocket/

uncovered expenses) $_________ __________ _________ _________

Prescriptions (out of pocket/

uncovered expenses) $_________ __________ _________ _________

Grooming $_________ __________ _________ _________

Gifts from children to others $_________ __________ _________ _________

Entertainment $_________ __________ _________ _________

Toys $_________ __________ _________ _________

Books/Publications $_________ __________ _________ _________

Summer camps $_________ __________ _________ _________

Sports and extracurricular

activities $_________ __________ _________ _________

Other (attach sheet) $_________ __________ _________ _________

Sub-total Child(ren) Expenses $ ______________

INSURANCE

Health

Total $_________

Child(ren) portion $_________ __________ _________ _________

Dental

Total $_________

Child(ren) portion $_________ __________ _________ _________

Vision

Total $_________

Child(ren) portion $_________ __________ _________ _________

Life Insurance on

child(ren)’s life only $_________ __________ _________ _________

Other (specify) $_________ __________ _________ _________

$ ________________

Sub-total Child(ren)’s Insurance $ _____________

TOTAL AVERAGE MONTHLY EXPENSES (Section A) $ _____________

Domestic Relations Financial Affidavit

Fulton County Family Division

B. PAYMENTS TO CREDITORS

Account # Monthly

To Whom (last 4 digits) Balance Due Payments Name(s)on Account

____________ __________ ___________ __________ _________________

TOTAL (Section B) $___________ $___________

C. TOTAL MONTHLY EXPENSES AND PAYMENTS

TO CREDITORS $________________

6. 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. “Non-marital” means your spouse or you had

this asset before the marriage or received it by personal gift or inheritance during the

marriage. The total value of each asset must be listed in the “value” column. “Value” means

what you believe to be the fair market value of the item or property.

ACCOUNT(S) ACCOUNT # VALUE HUSBAND’S WIFE’S

NAME (last 4 digits) Non-Marital Non-Marital

RETIREMENT ACCOUNTS:

401-K ______________ ___________ _________ ____________ ___________

Pension ______________ ___________ _________ ____________ ___________

IRA ______________ ___________ _________ ____________ ___________

Other ______________ ___________ _________ ____________ ___________

NON-RETIREMENT ACCOUNTS:

Stocks ______________ ___________ _________ ____________ ___________

Bonds ______________ ___________ _________ ____________ ___________

CDs ______________ ___________ _________ ____________ ___________

Investments ______________ ___________ _________ ____________ ___________

Money Market ______________ ___________ _________ ____________ ___________

Cash on hand _____________ ___________ _________ ____________ ___________

Other accounts _____________ ___________ _________ _____________ ___________

(Describe) _______________________________________________________________

________________________________________________________________________

Domestic Relations Financial Affidavit

Fulton County Family Division

BANK ACCOUNTS:

12 month

Average Current Name(s) on the

Name of Bank Account Number _Balance_ _Balance_ _Account______

(only last 4 digits)

Savings _____________ ______________ __________ __________ _______________

Checking _____________ ______________ __________ __________ _______________

Custodial _____________ ______________ __________ __________ _______________

Other _____________ ______________ __________ __________ _______________

REAL ESTATE: HUSBAND’S WIFE’S

Non-Marital Non-Marital

Home: Value ___________ _________________ ____________

Outstanding Loan balances ___________ _________________ ____________

Equity ___________ _________________ ____________

(Certified fair market value

minus loan balances)

Other real estate:

Name/Description

_______________ 1) Value ___________ _________________ ____________

Outstanding Loan balances ___________ _________________ ____________

Equity ___________ _________________ ____________

_______________ 2) Value ___________ _________________ ____________

Outstanding Loan balances ___________ _________________ ____________

Equity ___________ _________________ ____________

_______________ 3) Value ___________ _________________ ____________

Outstanding Loan balances ___________ _________________ ____________

Equity ___________ _________________ ____________

VALUE HUSBAND’S WIFE’S

Non-Marital Non-Marital

Money owed to you _____________ ______________ ____________

Tax refund due _____________ ______________ ____________

Life insurance

(cash surrender value) _____________ ______________ _____________

Furniture/furnishings _____________ ______________ _____________

Jewelry _____________ ______________ _____________

Collectibles _____________ ______________ _____________

Other _____________ ______________ _____________

Domestic Relations Financial Affidavit

Fulton County Family Division

MOTOR VEHICLES:

Year, Make and Model

Value Names(s) on title/Name(s) on loan/lease account

1) ____________________ ____________ _______________________________________

2) ____________________ ____________ _______________________________________

3) ____________________ ____________ _______________________________________

OTHER ASSETS

Are there any other assets, interest in assets or employment benefits that your spouse or you

have of a value greater than $999? If so, list your other assets here, (describe the asset, state

your estimate of the current fair market value and any amount you contend to be your spouse or

your non-marital interest):

________________________________________________________________________________

__________________________________________________________________________

NOTE: BUSINESS INTERESTS– see required attached form labeled “Business Interests”

 Check if Business Interests form is attached

Domestic Relations Financial Affidavit

Fulton County Family Division

BUSINESS INTERESTS

The term “Business” for purposes of this form and your disclosure includes any business entity or

business operation of any kind in which you have any claim or ownership interest including, without limitation,

your claim or interest in any sole proprietorship, partnership, limited partnership, limited liability company,

joint venture, syndicate, closely held corporation, sub-chapter S corporation or any other type of business entity

in Georgia or any other jurisdiction.

For each Business in which you have any claim, interest or ownership, list separately and completely the

information in the form below and produce the documents required in this section.

Legal name of Business

(and d/b/a if any)

Type of business

entity (i.e. Sub-S

Corp., C Corp.,

LLC, LLP,

Partnership, Sole

Proprietorship etc.)

Business activity Percentage

of

ownership

Date business

interest acquired

Estimated fair

market value of

ownership

interest

Percentage of

total interest

that is non-

marital

For each Business Interest you have listed above, attach copies of corporate or partnership income tax

returns for the last three years; and attach annual financial statements for the last full year as well as financial

statements from the end of the last full year until the present. The term “financial statements” includes, at a

minimum, income and profit and loss statements and balance sheets showing assets and liabilities including

without limitation current accounts receivable and payable.

For the last three years, for sole proprietorships, produce your IRS Schedule C forms with your Form

1040 personal tax returns. Also produce related bank account records as well as statements of income, expenses,

and current accounts receivable and payable.

Domestic Relations Financial Affidavit

Fulton County Family Division

I AM AWARE THAT ANY FALSE STATEMENT KNOWINGLY MADE WITH THE

INTENT TO DEFRAUD OR MISLEAD SHALL SUBJECT ME TO THE PENALTY FOR

PERJURY AND MAY BE CONSIDERED A FRAUD UPON THE COURT.

I DECLARE THAT THE ABOVE INFORMATION IS TRUE AND THAT THE

INFORMATION CONTAINED IN THIS FORM CONSTITUES A COMPLETE AND FULL

DISCLOSURE OF MY FINANCIAL CONDITION.

__________________________________________

Printed Name

__________________________________________

Address

__________________________________________

City State Zip

__________________________________________

Telephone (area code and number)

__________________________________________

Facsimile (area code and number)

STATE OF GEORGIA

COUNTY OF __________________

Sworn to and subscribed before me

on this ____ day of ________, 20___.

__________________________________________

NOTARY PUBLIC

(Print, type or stamp commissioned name of notary)

Domestic Relations Financial Affidavit

Fulton County Family Division

IN THE SUPERIOR COURT OF FULTON COUNTY

STATE OF GEORGIA

FAMILY DIVISION

, )

)

Petitioner, )

) Civil Action File No.

and )

)

, )

)

Respondent. )

)

CERTIFICATE OF SERVICE

I CERTIFY THAT THE FINANCIAL AFFIDAVIT WAS:

(check one only) _____ mailed, _______facsimiled and mailed, or _____ hand delivered to the

person(s) listed below on the _______ day of _________________, 200____.

Party or their attorney if represented:

Name _________________________

Address _______________________

______________________________

Telephone No. _________________

Facsimile No. ___________________

DATED: _______________________ ___________________________________

Signature of party or attorney, if party is

represented by counsel

Printed name ________________________

Address ____________________________

____________________________________

Telephone (area code and number)

____________________________________

Facsimile (area code and number)

Domestic Relations Financial Affidavit

Fulton County Family Division