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UNCONTESTED CHANGE OF CUSTODY COLUMBIA JUDICIAL CIRCUIT LAST UPDATED 10/17/2022 Page 1 of 33 UNCONTESTED CHANGE OF CUSTODY A change of custody is allowed when the parent(s) can prove that there are substantial changes affecting the welfare and best interests of the child(ren). Parents can enter into an agreement regarding custody, subject to the court’s approval. The parental agreement will be effective unless the judge decides that the proposed change is not in the best interests of the childr(en). The parents’ agreement can be made a Final Order of modification by the trial court at any time after the agreement has been submitted to the Court. When a parent sues the other parent to change custody, the court has the power to award sole custody, joint custody, joint legal custody, and joint physical custody. Additionally, the court may award custody to a third person when both parents are proved to be unfit. The Judge has the power to Order a evaluation of the family, an independent medical evaluation, or an investigation by the local family and children services agency. A complaint for change of custody brought by the non-custodial parent must be brought in the county in which the legal custodian of the child or children. A complaint for change of custody brought by the legal custodian must be brought in the county in which the Defendant resides. A Judge may consider the desire of a child who is at least eleven years of age, but not yet fourteen. However, the child’s desire by itself is not a material change of conditions or circumstances. The wishes of a child aged fourteen or older is controlling unless the parent whom the child chooses is unfit. During a custody hearing, the trial court may Order the parents to leave the courtroom when a child testifies. ---PAGE BREAK--- UNCONTESTED CHANGE OF CUSTODY COLUMBIA JUDICIAL CIRCUIT LAST UPDATED 10/17/2022 Page 2 of 33 IN THE SUPERIOR COURT OF COLUMBIA COUNTY STATE OF GEORGIA , * PLAINTIFF, * * CASE NUMBER: v. * * , * DEFENDANT. * COMPLAINT FOR CHANGE OF CUSTODY Now comes the Plaintiff, , and states his/her claim against the Defendant, , for a change of custody as follows: 1. Jurisdiction and Venue (choose a or b) a) The Defendant is subject to the jurisdiction of this Court and has signed an Acknowledgment of Service and Summons. b) The Defendant is not subject to the jurisdiction of this Court, but has signed an Affidavit of Waiver of Venue and Personal Jurisdiction. 2. Current Custody Arrangement (choose a or b) a) The Defendant presently has legal custody of the minor child(ren), , age(s) , by virtue of a Final Order and decree of divorce in Civil Action No. , entered on the day of , 20 in the Superior Court of County, Georgia. b) The Defendant presently has legal custody of the minor child(ren), , age(s) , by virtue of an Order of legitimation in Civil Action No. , entered on the day of , 20 . ---PAGE BREAK--- UNCONTESTED CHANGE OF CUSTODY COLUMBIA JUDICIAL CIRCUIT LAST UPDATED 10/17/2022 Page 3 of 33 3. Change in Circumstances There has been a change in circumstances materially affecting the welfare of the minor child(ren) as follows: 4. Proposed New Custody Arrangement As a result of such change of circumstances, the Plaintiff and Defendant have agreed that custody should be as follows: 5. Plaintiff’s Ability to be Custodial Parent The Plaintiff is a fit and capable parent and is otherwise qualified to assume full custody of the minor child(ren). THEREFORE, Plaintiff prays: That custody of the minor child(ren) be changed as follows: That the Plaintiff have such additional relief as the Court may consider equitable and appropriate. Plaintiff pro se Address: Telephone number(s): ---PAGE BREAK--- UNCONTESTED CHANGE OF CUSTODY COLUMBIA JUDICIAL CIRCUIT LAST UPDATED 10/17/2022 Page 4 of 33 IN THE SUPERIOR COURT OF COLUMBIA COUNTY STATE OF GEORGIA , * PLAINTIFF, * * CASE NUMBER: v. * * , * DEFENDANT. * VERIFICATION Personally appeared before me the undersigned who on oath states that the facts set forth in this Complaint are true and correct to the best of his/her knowledge and belief. Plaintiff pro se Sworn to and subscribed before me this day of , 20 . Notary Public, State of Georgia My Commission Expires: ---PAGE BREAK--- UNCONTESTED CHANGE OF CUSTODY COLUMBIA JUDICIAL CIRCUIT LAST UPDATED 10/17/2022 Page 5 of 33 IN THE SUPERIOR COURT OF COLUMBIA COUNTY STATE OF GEORGIA , * PLAINTIFF, * * CASE NUMBER: v. * * , * DEFENDANT. * PLAINTIFF’S AFFIDAVIT REQUIRED BY O.C.G.A. § 19-9-69 State of Georgia County of Personally before the undersigned officer authorized to administer oaths appeared, who, being duly sworn, does state on oath the following: 1. That Affiant, , is the plaintiff named in the above- styled action. 2. The above-styled action concerns the custody of: Name: DOB: Sex: Name: DOB: Sex: Name: DOB: Sex: Name: DOB: Sex: 3. The present address of the child(ren) is: ---PAGE BREAK--- UNCONTESTED CHANGE OF CUSTODY COLUMBIA JUDICIAL CIRCUIT LAST UPDATED 10/17/2022 Page 6 of 33 4. For the past five years, the children lived at the following addresses with the following persons: Address Dates Lived With 5. The child(ren) presently live/lives with . 6. Other Cases Concerning the Child(ren) (Choose a or b) a) Plaintiff asserts that he/she has not participated as a party or a witness or in any other capacity in any other litigation concerning the children named above, and knows of no other proceeding concerning the minor children in this or any other state. No person other than the parties to this action has physical custody of the minor children or any claim to custody or visitation with the minor children. b) The minor children have been involved in the following custody actions: (The court wants to know about the following types of actions: custody, visitation, family violence, protective Orders, termination of parental rights, and adoption.) County/State/Court Type of Custody Action Date Filed Status ---PAGE BREAK--- UNCONTESTED CHANGE OF CUSTODY COLUMBIA JUDICIAL CIRCUIT LAST UPDATED 10/17/2022 Page 7 of 33 7. Others with a Custody/Visitation Claim (Choose a or b) a) I know of no other person, not a party to this proceeding, who has physical custody of the children or claims to have custody or visitation rights with respect to the minor children. b) The following persons who are not a party to this proceeding have custody or visitation rights with the minor children: Name Claim Affiant/Plaintiff Sworn to and subscribed before me this day of , 20 . Notary Public ---PAGE BREAK--- UNCONTESTED CHANGE OF CUSTODY COLUMBIA JUDICIAL CIRCUIT LAST UPDATED 10/17/2022 Page 8 of 33 IN THE SUPERIOR COURT OF COLUMBIA COUNTY STATE OF GEORGIA , * PLAINTIFF, * * CASE NUMBER: v. * * , * DEFENDANT. * ELECTION OF . This Affidavit is given by who, after being duly sworn before an officer authorized in the State of Georgia to administer oaths, states the following: 1. My name is , and I am the son or daughter of and . I was born on and am currently years old. 2. I sign this Affidavit to inform the court that I wish to live and elect to live with my [mother/father/other] on a permanent and full-time basis. I understand that my [mother/father/other] may ask the Court to be made my custodial parent and desire that he be designated as my custodial parent. 3. I wish my [non-custodial parent] to have reasonable visitation rights. 4. I hereby affirm that I have given this Affidavit under oath and that the statements contained herein are true and accurate. ---PAGE BREAK--- UNCONTESTED CHANGE OF CUSTODY COLUMBIA JUDICIAL CIRCUIT LAST UPDATED 10/17/2022 Page 9 of 33 5. I have made this election voluntarily and not because of any pressure or duress or because of any problems made known to me by either of my parents or any other person. Affiant Sworn to and subscribed before me this day of , 20 . Notary Public My Commission Expires: ---PAGE BREAK--- UNCONTESTED CHANGE OF CUSTODY COLUMBIA JUDICIAL CIRCUIT LAST UPDATED 10/17/2022 Page 10 of 33 IN THE SUPERIOR COURT OF COLUMBIA COUNTY STATE OF GEORGIA , * PLAINTIFF, * * CASE NUMBER: v. * * , * DEFENDANT. * ACKNOWLEDGMENT OF SERVICE AND SUMMONS The undersigned Defendant hereby acknowledges service of the above Summons and Complaint for Divorce and states that he/she has received a copy of said Complaint, and Defendant hereby waives any further service of process. This the day of , 20 . Defendant pro se Sworn to and subscribed before me this day of , 20 . Notary Public My Commission Expires: ---PAGE BREAK--- UNCONTESTED CHANGE OF CUSTODY COLUMBIA JUDICIAL CIRCUIT LAST UPDATED 10/17/2022 Page 11 of 33 IN THE SUPERIOR COURT OF COLUMBIA COUNTY STATE OF GEORGIA , * PLAINTIFF, * * CASE NUMBER: v. * * , * DEFENDANT. * DEFENDANT’S ACKNOWLEDGMENT OF SERVICE AFFIDAVIT OF WAIVER OF VENUE AND PERSONAL JURISDICTION I, , the named Defendant in the above-styled case, after being duly sworn do hereby depose and say that I am a resident of County, (State), and that the Plaintiff in the above-styled case is a resident of County, Georgia. I affirm that I have received a copy of said Petition/Complaint, and I hereby waive any and all further notice, service, and issuance of process. After being duly informed that I have a constitutional right to a trial by judge or jury on the above matter in the county of my residence, and with that knowledge, I hereby expressly waive my right to venue in the county of my residence, and consent to venue and personal jurisdiction in the county of this superior court. This day of , 20 . Affiant Notary Public Sworn to and subscribed before me this day of , 20 . ---PAGE BREAK--- UNCONTESTED CHANGE OF CUSTODY COLUMBIA JUDICIAL CIRCUIT LAST UPDATED 10/17/2022 Page 12 of 33 IN THE SUPERIOR COURT OF COLUMBIA COUNTY STATE OF GEORGIA , * PLAINTIFF, * * CASE NUMBER: v. * * , * DEFENDANT. * CUSTODY AGREEMENT This is an agreement by and between , (hereinafter referred to as “Father”) and , (hereinafter referred to as“Mother”). WHEREAS, the parties desire to settle between themselves all questions regarding child custody, visitation, child support, and all other rights and obligations arising out of their former marital relationship: NOW, THEREFORE, in consideration of the mutual covenants hereinafter contained, the parties agree as follows: 1. Non-interference with Parental Relationships The parties agree that the welfare of the child(ren) is of paramount importance and each agrees to foster and encourage a feeling of affection between themselves and the child(ren). Neither party shall do anything to hamper the natural development of the children’s love and respect for the other party. 2. Legal and Physical Custody (Check a, b, or c) a) The Father/Mother shall have the temporary and permanent legal and physical custody of the minor child (ren) born as issue of the marriage. b) The Father and Mother shall share joint legal custody of the minor child(ren). The parties shall share decision-making concerning the children; however, the Father/Mother shall have the right to make the final decision in the event the parties cannot agree. ---PAGE BREAK--- UNCONTESTED CHANGE OF CUSTODY COLUMBIA JUDICIAL CIRCUIT LAST UPDATED 10/17/2022 Page 13 of 33 Primary physical custody of the minor child (ren) shall be with the Father/Mother as follows: Secondary physical custody shall be with the Father/Mother as follows: The Father and Mother shall share joint legal custody and joint physical custody of the minor child (ren). Physical custody shall be shared by the parties as follows: The parties shall share decision making concerning the child (ren); however, in the event the parties cannot decide, the Father/Mother shall have the final decision concerning 3. Visitation Schedule (Choose a or b) a) The Father/Mother shall have the right of visitation with the minor children as follows: b) The visitation schedule is attached hereto and incorporated herein. ---PAGE BREAK--- UNCONTESTED CHANGE OF CUSTODY COLUMBIA JUDICIAL CIRCUIT LAST UPDATED 10/17/2022 Page 14 of 33 4. Cooperation and Consultation This Agreement cannot provide for every possible detail with respect to the custody of the Child(ren). In that regard, the parties agree to cooperate and consult with each other so as to carry out visitation in a manner conducive to the best interests of the Child(ren). Neither party shall attempt to influence any of the Child(ren) not to love and respect the other parent. Each party agrees to keep the other informed as to the health and whereabouts of the Child(ren) while having custody of or visitation with the child(ren). 5. Change of Residence In the event of any change of residence on the part of either party herein so long as the custody and visitation provisions of this Agreement are in effect, said party changing his or her residence shall notify the other party at least one month in advance of the intent to change residence and of the location of the new residence and shall furnish to him or her the complete new address and, as soon as determined, the new telephone number at the new residence. Said notification shall be in writing with a copy of said writing retained by the other CHILD SUPPORT Please go to and complete the Child Support Worksheet 6. Child Support Amount The Father/Mother shall pay to the Father/Mother, as support of the minor child(ren), the sum of $ * per week/bi-weekly/month, starting on , and continuing per week/bi-weekly/month thereafter until each respective child reaches the age of eighteen (18), or so long as the child is enrolled in and attending secondary school (not to exceed age twenty marries, dies, or becomes otherwise emancipated. The child support obligation shall be reduced as follows as each child becomes emancipated: * This amount was derived from Line 13 of the Child Support Worksheet, which is attached hereto as Exhibit 1. ---PAGE BREAK--- UNCONTESTED CHANGE OF CUSTODY COLUMBIA JUDICIAL CIRCUIT LAST UPDATED 10/17/2022 Page 15 of 33 7. Child Support Method of Payment (Check a or b) a) All payments of child support shall be paid directly to the Father/Mother at the following address: . No Income Deduction Order will be entered into at this time. However, when ever, in violation of the terms of this Agreement, there shall have been a failure to make the support payments due hereunder so that the amount unpaid is equal to or greater than the amount payable for one month, the payments required to be made may be collected by the process of continuing garnishment for support. In the event Father/Mother fails to pay any child support obligation in this Agreement on a timely fashion on any three occasions in any twelve (12) month period, the parties agree that an income deduction Order shall then be entered. b) All payments of child support shall be paid to Georgia Child Support Enforcement pursuant to an Income Deduction Order. 8. Health Insurance The Father/Mother shall maintain a policy of medical, dental, and hospitalization insurance for the benefit of the minor child(ren) for so long as the child support obligation set forth herein exists. Costs not covered under the insurance policy shall be divided between Father and Mother as follows: The Father/Mother shall provide the Father/Mother with an insurance identification card or such other acceptable proof of insurance coverage and shall cooperate with the Father/Mother in submitting claims under the policy. BINDING AGREEMENT 9. Voluntary Agreement The parties acknowledge that they have entered into this Agreement freely and voluntarily and that it is not the result of any duress or any undue influence. ---PAGE BREAK--- UNCONTESTED CHANGE OF CUSTODY COLUMBIA JUDICIAL CIRCUIT LAST UPDATED 10/17/2022 Page 16 of 33 10. Entire Agreement This Agreement constitutes the entire understanding of the parties. There are no representations, warranties, covenants, or undertaking other than those expressly set forth herein. Plaintiff pro se Sworn to and subscribed before me this day of , 20 . Notary Public, State of Georgia My Commission Expires: Defendant pro se Sworn to and subscribed before me this day of , 20 . Notary Public, State of Georgia My Commission Expires: ---PAGE BREAK--- UNCONTESTED CHANGE OF CUSTODY COLUMBIA JUDICIAL CIRCUIT LAST UPDATED 10/17/2022 Page 17 of 33 Exhibit “ ” VISITATION SCHEDULE The non-custodial parent is . The custodial parent is . The non-custodial parent shall be entitled to exercise reasonable visitation with the minor child with the following minimum provisions: A. On every 1st , 3rd , and 5th Friday at 6:00 p.m. until the following Sunday at 6:00 p.m.; B. During even numbered years (2008, 2010, etc.), the non-custodial parent shall have the right of visitation on the holidays delineated below: 1. Martin Luther King’s Birthday 2. Memorial Day 3. Labor Day 4. Thanksgiving 5. Second week of Christmas Vacation from 2:00 p.m. on December 25 until New Year’s Eve. C. During odd numbered years (2009, 2011, etc.,) the non-custodial parent shall have the right of visitation on the holidays delineated below: 1. New Year’s Day 2. Easter or Spring Break 3. July 4th 4. Halloween 5. First Week of Christmas vacation, including Christmas Day until 2:00 p.m. on December 25. D. During even numbered years (2008, 2010, etc.), the custodial parent shall have the minor child on the holidays delineated below: 1. New Year’s Day 2. Easter or Spring Break 3. July 4th 4. Halloween 5. First week of Christmas vacation, including Christmas Day until 2:00 p.m. on December 25. E. During odd numbered years (2009, 2011, etc.), the custodial parent shall have the ---PAGE BREAK--- UNCONTESTED CHANGE OF CUSTODY COLUMBIA JUDICIAL CIRCUIT LAST UPDATED 10/17/2022 Page 18 of 33 right of visitation on the holidays delineated below: 1. Martin Luther King’s Birthday 2. Memorial Day 3. Labor Day 4. Thanksgiving 5. Second week of Christmas vacation from 2:00 p.m. on December 25 until New Year’s Eve. F. The Mother shall have the minor child on Mother’s Day. G. The Father shall have the minor child on Father’s Day. H. The non-custodial parent shall have the right to visit with the minor child for two consecutive weeks in the summer between June 15 and August 15. During this period, the custodial parent shall have the minor child on the first (1st) weekend from 6:00 p.m. Friday until 6:00 p.m. Sunday. The non-custodial parent shall give the custodial parent a minimum of thirty (30) days written notice of the intent to exercise this visitation. I. Holiday visitation shall take precedence over week-end visitation. ---PAGE BREAK--- UNCONTESTED CHANGE OF CUSTODY COLUMBIA JUDICIAL CIRCUIT LAST UPDATED 10/17/2022 Page 19 of 33 IN THE SUPERIOR COURT OF COLUMBIA COUNTY STATE OF GEORGIA , * PLAINTIFF, * * CASE NUMBER: v. * * , * DEFENDANT. * DOMESTIC RELATIONS FINANCIAL AFFIDAVIT OF MOTHER 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 Gross income (from item 3A) $ Net income (from item 3C) $ Average expenses (item 5A) $ ---PAGE BREAK--- UNCONTESTED CHANGE OF CUSTODY COLUMBIA JUDICIAL CIRCUIT LAST UPDATED 10/17/2022 Page 20 of 33 payments to creditors + Total expenses and payments to credits (item 5C) $ (subsections & deleted) 3. A AFFIANT’S GROSS INCOME (complete this section or attach Child Support Schedule A) (All income must be entered based on average regardless of date of receipt.) Salary or Wage $ 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 $ ---PAGE BREAK--- UNCONTESTED CHANGE OF CUSTODY COLUMBIA JUDICIAL CIRCUIT LAST UPDATED 10/17/2022 Page 21 of 33 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 INCOME $ (prior section B deleted) 3. B Affiant’s Net Income from employment (deducting only state and federal taxes and FICA) $ Affiant’s pay period weekly, 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: premarital, gift, inheritance, source of funds, etc.) Description Value Separate Asset of the Husband Separate Asset of the Wife Basis of the Claim Cash $ Stocks, bonds $ CD’s/Money Market Accounts $ Bank Accounts (list each account): $ $ $ ---PAGE BREAK--- UNCONTESTED CHANGE OF CUSTODY COLUMBIA JUDICIAL CIRCUIT LAST UPDATED 10/17/2022 Page 22 of 33 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: debt owed: $ $ Vehicle 2: debt owed: $ $ Life Insurance (net cash value): $ Furniture/furnishings: $ Jewelry: $ Collectibles: $ Other Assets: $ $ $ $ Total Assets: $ ---PAGE BREAK--- UNCONTESTED CHANGE OF CUSTODY COLUMBIA JUDICIAL CIRCUIT LAST UPDATED 10/17/2022 Page 23 of 33 5. A AVERAGE 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 $ Auto Tags and license $ Telephone: $ Insurance $ residential line: $ cellular telephone: $ Gas $ OTHER VEHICLES (boats, trailers, RVs, etc.) Repairs and maintenance: $ Gasoline and oil $ Repairs $ Lawn Care $ Tags and license $ Insurance $ Pest Control $ CHILDREN’S EXPENSES AFFIANT’S OTHER EXPENSES Child care (total cost) $ Dry cleaning/laundry $ School tuition $ Clothing $ Tutoring $ Medical, dental, prescription (out of pocket/uncovered expenses) Private lessons music, dance) $ $ Affiant’s gifts $ (special holidays) School supplies/expenses $ Entertainment $ Lunch Money $ Recreational Expen. $ fitness) Vacations $ ---PAGE BREAK--- UNCONTESTED CHANGE OF CUSTODY COLUMBIA JUDICIAL CIRCUIT LAST UPDATED 10/17/2022 Page 24 of 33 Other Educational Expenses (list) $ Travel Exp/Visitation $ $ Publications $ Allowance $ Dues, clubs $ Clothing $ Religious and charities $ Diapers $ Pet expenses $ Medical, dental, prescription (out of pocket/uncovered expenses) $ Alimony paid to former spouse $ 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): $ TOTAL ABOVE EXPENSES $ ---PAGE BREAK--- UNCONTESTED CHANGE OF CUSTODY COLUMBIA JUDICIAL CIRCUIT LAST UPDATED 10/17/2022 Page 25 of 33 B. PAYMENTS TO CREDITORS (please check one) (please check one) To Whom: Balance Due Joint Plaintiff Defendant Payment ---PAGE BREAK--- UNCONTESTED CHANGE OF CUSTODY COLUMBIA JUDICIAL CIRCUIT LAST UPDATED 10/17/2022 Page 26 of 33 TOTAL PAYMENTS TO CREDITORS: $ C. TOTAL EXPENSE: $ This day of , 20 . Affiant Notary Public My Commission expires: ---PAGE BREAK--- UNCONTESTED CHANGE OF CUSTODY COLUMBIA JUDICIAL CIRCUIT LAST UPDATED 10/17/2022 Page 27 of 33 IN THE SUPERIOR COURT OF COUNTY STATE OF GEORGIA , § Plaintiff, § v. Civil Action § File No. , Defendant. § DOMESTIC RELATIONS FINANCIAL AFFIDAVIT OF FATHER 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 Gross income (from item 3A) $ Net income (from item 3C) $ Average expenses (item 5A) $ ---PAGE BREAK--- UNCONTESTED CHANGE OF CUSTODY COLUMBIA JUDICIAL CIRCUIT LAST UPDATED 10/17/2022 Page 28 of 33 payments to creditors + Total expenses and payments to credits (item 5C) $ (subsections & deleted) 3. A AFFIANT’S GROSS INCOME (complete this section or attach Child Support Schedule A) (All income must be entered based on average regardless of date of receipt.) Salary or Wage $ 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 $ ---PAGE BREAK--- UNCONTESTED CHANGE OF CUSTODY COLUMBIA JUDICIAL CIRCUIT LAST UPDATED 10/17/2022 Page 29 of 33 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 INCOME $ (prior section B deleted) 3. B Affiant’s Net Income from employment (deducting only state and federal taxes and FICA) $ Affiant’s pay period weekly, 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: premarital, gift, inheritance, source of funds, etc.) Description Value Separate Asset of the Husband Separate Asset of the Wife Basis of the Claim Cash $ Stocks, bonds $ CD’s/Money Market Accounts $ Bank Accounts (list each account): $ $ $ ---PAGE BREAK--- UNCONTESTED CHANGE OF CUSTODY COLUMBIA JUDICIAL CIRCUIT LAST UPDATED 10/17/2022 Page 30 of 33 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: debt owed: $ $ Vehicle 2: debt owed: $ $ Life Insurance (net cash value): $ Furniture/furnishings: $ Jewelry: $ Collectibles: $ Other Assets: $ $ $ $ Total Assets: $ ---PAGE BREAK--- UNCONTESTED CHANGE OF CUSTODY COLUMBIA JUDICIAL CIRCUIT LAST UPDATED 10/17/2022 Page 31 of 33 5. A AVERAGE 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 $ Auto Tags and license $ Telephone: $ Insurance $ residential line: $ cellular telephone: $ Gas $ OTHER VEHICLES (boats, trailers, RVs, etc.) Repairs and maintenance: $ Gasoline and oil $ Repairs $ Lawn Care $ Tags and license $ Insurance $ Pest Control $ CHILDREN’S EXPENSES AFFIANT’S OTHER EXPENSES Child care (total cost) $ Dry cleaning/laundry $ School tuition $ Clothing $ Tutoring $ Medical, dental, prescription (out of pocket/uncovered expenses) Private lessons music, dance) $ $ Affiant’s gifts $ (special holidays) School supplies/expenses $ Entertainment $ Lunch Money $ Recreational Expen. $ fitness) Other Educational Expenses (list) Vacations $ ---PAGE BREAK--- UNCONTESTED CHANGE OF CUSTODY COLUMBIA JUDICIAL CIRCUIT LAST UPDATED 10/17/2022 Page 32 of 33 $ Travel Exp/Visitation $ $ Publications $ Allowance $ Dues, clubs $ Clothing $ Religious and charities $ Diapers $ Pet expenses $ Medical, dental, prescription (out of pocket/uncovered expenses) $ Alimony paid to former spouse $ 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): $ TOTAL ABOVE EXPENSES $ ---PAGE BREAK--- UNCONTESTED CHANGE OF CUSTODY COLUMBIA JUDICIAL CIRCUIT LAST UPDATED 10/17/2022 Page 33 of 33 B. PAYMENTS TO CREDITORS (please check one) (please check one) To Whom: Balance Due Joint Plaintiff Defendant Payment TOTAL PAYMENTS TO CREDITORS: $ C. TOTAL EXPENSE: $ This day of , 20 . Affiant Notary Public