Full Text
DOMESTIC RELATIONS FINANCIAL AFFIDAVIT—COLUMBIA JUDICIAL CIRCUIT Last Updated 10/17/2022 Page 1 of 6 IN THE SUPERIOR COURT OF COLUMBIA COUNTY STATE OF GEORGIA , * PLAINTIFF, * * CASE NUMBER: v. * * , * DEFENDANT. * DOMESTIC RELATIONS FINANCIAL AFFIDAVIT 1. AFFIANT’S 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) $ payments to creditors + ---PAGE BREAK--- DOMESTIC RELATIONS FINANCIAL AFFIDAVIT—COLUMBIA JUDICIAL CIRCUIT Last Updated 10/17/2022 Page 2 of 6 Total expenses and payments to creditors (item 5C) $ 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 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 INCOME $ ---PAGE BREAK--- DOMESTIC RELATIONS FINANCIAL AFFIDAVIT—COLUMBIA JUDICIAL CIRCUIT Last Updated 10/17/2022 Page 3 of 6 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: pre-marital, 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): Retirement Pensions, 401K, IRA, or Profit Sharing Money owed you: Tax Refund owed you: Real Estate: home: $ debt owed: $ other: debt owed: $ ---PAGE BREAK--- DOMESTIC RELATIONS FINANCIAL AFFIDAVIT—COLUMBIA JUDICIAL CIRCUIT Last Updated 10/17/2022 Page 4 of 6 Automobiles/Vehicles: Vehicle 1: debt owed: $ Vehicle 2: debt owed: Life Insurance (net cash value): Furniture/furnishings: Jewelry: Collectibles: Other Assets: Total Assets: 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 Garbage and Sewer $ Gasoline and oil $ Telephone: Repairs $ residential line: $ Auto tags and license $ cellular telephone: $ Insurance $ Gas $ OTHER VEHICLES (boats, trailers, RVs, etc.) Repairs and maintenance: $ Gasoline and oil Lawn Care $ Repairs Pest Control $ Tags and license CHILDREN’S EXPENSES Insurance Child care (total cost) AFFIANT’S OTHER EXPENSES School tuition Dry cleaning/laundry Tutoring Clothing Private lessons (e.g. music dance) Medical, dental, prescription (out of pocket/uncovereds) School supplies/expenses Affiant’s gifts (special holidays) ---PAGE BREAK--- DOMESTIC RELATIONS FINANCIAL AFFIDAVIT—COLUMBIA JUDICIAL CIRCUIT Last Updated 10/17/2022 Page 5 of 6 Lunch Money Entertainment Other Educational Expenses (list) Recreational Expenses fitness) Vacations Travel Expenses for Visitation Allowance Publications Clothing Dues, clubs Diapers Religious and charities Medical, dental, prescription (out of pocket/uncovered expenses) Pet expenses Grooming, hygiene Alimony paid to former spouse Gifts from children to others Child support paid for other children Entertainment Date of initial order: Activities (including extra-curricular, school, religious, cultural, etc.) Other (attach sheet) Summer Camps OTHER INSURANCE Health Child(ren)’s portion: TOTAL ABOVE EXPENSES Dental Child(ren)’s portion: Vision Child(ren)’s portion: Life Relationship of Beneficiary: Disability Other(specify): ---PAGE BREAK--- DOMESTIC RELATIONS FINANCIAL AFFIDAVIT—COLUMBIA JUDICIAL CIRCUIT Last Updated 10/17/2022 Page 6 of 6 B. PAYMENTS TO CREDITORS (please check one) To Whom: Balance Due Payment Joint Plaintiff Defendant TOTAL PAYMENTS TO CREDITORS: $ C. TOTAL EXPENSES: $ This day of Affiant Sworn to and subscribed before me, this day of 20 Notary Public (SEAL)