In the Superior Court of ______ County, Georgia

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) ______

Monthly payments to creditors + ______

Total monthly expenses and payments to creditors (item 5C) ______

1 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 $ ______2 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: $______

debt owed: $ ______3 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 $______

4 CHILDREN’S EXPENSES AFFIANT’S OTHER EXPENSES

5 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): $______TOTAL ABOVE EXPENSES $ ______

6 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

7 Rule 24.4. Temporary hearing, scheduling.

RESERVED. (Former Rule 24.4 is now incorporated in Rule 24.2).