<p> In the Superior Court of ______County, Georgia</p><p>) ______, Plaintiff ) ) vs. ) Civil Action No. ______) ______, Defendant ) )</p><p>DOMESTIC RELATIONS FINANCIAL AFFIDAVIT</p><p>1. AFFIANT’S NAME:______Age ______</p><p>Spouse’s Name: ______Age ______</p><p>Date of Marriage: ______Date of Separation ______</p><p>Names and birth dates of children for whom support is to be determined in this action:</p><p>Name Date of Birth Resides with</p><p>______</p><p>______</p><p>______</p><p>Names and birth dates of affiant’s other children:</p><p>Name Date of Birth Resides with</p><p>______</p><p>______</p><p>______</p><p>2. SUMMARY OF AFFIANT’S INCOME AND NEEDS</p><p>(a) Gross monthly income (from item 3A) $ ______</p><p>(b) Net monthly income (from item 3C) ______</p><p>(c) Average monthly expenses (item 5A) $ ______</p><p>Monthly payments to creditors + ______</p><p>Total monthly expenses and payments to creditors (item 5C) ______</p><p>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.)</p><p>Salary or Wages $ ______ATTACH COPIES OF 2 MOST RECENT WAGE STATEMENTS</p><p>Commissions, Fees, Tips $ ______</p><p>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 $ ______</p><p>Rental Income (gross receipts minus ordinary and necessary expenses required to produce income) ATTACH SHEET ITEMIZING YOUR CALCULATIONS $ ______</p><p>Bonuses $ ______</p><p>Overtime Payments $ ______</p><p>Severance Pay $ ______</p><p>Recurring Income from Pensions or Retirement Plans $ ______</p><p>Interest and Dividends $ ______</p><p>Trust Income $ ______</p><p>Income from Annuities $ ______</p><p>Capital Gains $ ______</p><p>Social Security Disability or Retirement Benefits $ ______</p><p>Workers’ Compensation Benefits $ ______</p><p>Unemployment Benefits $ ______</p><p>Judgments from Personal Injury or Other Civil Cases $ ______</p><p>Gifts (cash or other gifts that can be converted to cash) $ ______</p><p>Prizes/Lottery Winnings $ ______</p><p>Alimony and maintenance from persons not in this case $ ______</p><p>Assets which are used for support of family $ ______</p><p>Fringe Benefits (if significantly reduce living expenses) $ ______</p><p>Any other income (do NOT include means-tested Public assistance, such as TANF or food stamps) $ ______</p><p>GROSS MONTHLY INCOME $ ______2 B. Affiant’s Net Monthly Income from employment (deducting only state and federal taxes and FICA) $ ______</p><p>Affiant’s pay period (i.e., weekly, monthly, etc.) ______</p><p>Number of exemptions claimed ______</p><p>4. ASSETS</p><p>(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.).</p><p>Description Value Separate Asset Separate Asset Basis of the of the Husband of the Wife Claim</p><p>Cash $______</p><p>Stocks, bonds $______</p><p>CD’s/Money Market $______Accounts</p><p>Bank Accounts (list each account):</p><p>______$______</p><p>______$______</p><p>______$______</p><p>Retirement Pensions, 401K, IRA, or $______Profit Sharing</p><p>Money owed you: $______</p><p>Tax Refund owed you: $______</p><p>Real Estate:</p><p> home: $ ______</p><p> debt owed: $ ______</p><p> other: $______</p><p> debt owed: $ ______Automobiles/Vehicles: Vehicle 1: $______</p><p> debt owed: $ ______3 Vehicle 2: $______</p><p> debt owed: $______</p><p>Life Insurance (net cash value): $______</p><p>Furniture/furnishings: $______</p><p>Jewelry: $______</p><p>Collectibles: $______</p><p>Other Assets: $______</p><p>______$______</p><p>______$______</p><p>______$______</p><p>Total Assets: $______</p><p>5. A. AVERAGE MONTHLY EXPENSES</p><p>HOUSEHOLD Mortgage or rent payments $ ______Cable TV $ ______</p><p>Property taxes $ ______Misc. household and grocery Items $ ______</p><p>Homeowner/Renter Insurance $ ______Meals outside the home $ ______</p><p>Electricity $ ______Other $ ______</p><p>Water $ ______AUTOMOBILE Gasoline and oil $ ______Garbage and Sewer $ ______Repairs $ ______Telephone: residential line: $ ______Auto tags and license $ ______</p><p> cellular telephone: $ ______Insurance $ ______</p><p>Gas $ ______OTHER VEHICLES (boats, trailers, RVs, etc.) Gasoline and oil $______Repairs and maintenance: $ ______Repairs $______Lawn Care $ ______Tags and license $______Pest Control $ ______Insurance $______</p><p>4 CHILDREN’S EXPENSES AFFIANT’S OTHER EXPENSES</p><p>5 Child care (total monthly cost) $______Dry cleaning/laundry $______</p><p>School tuition $______Clothing $______</p><p>Tutoring $______Medical, dental, prescription (out of pocket/uncovered expenses) $______Private lessons (e.g., music, dance) $______Affiant’s gifts (special holidays) $______</p><p>School supplies/expenses $______Entertainment $______</p><p>Lunch Money $______Recreational Expenses (e.g., $______fitness)</p><p>Other Educational Expenses (list) Vacations $______</p><p>______$______Travel Expenses for Visitation $______</p><p>______$______Publications $______</p><p>Allowance $______Dues, clubs $______</p><p>Clothing $______Religious and charities $______</p><p>Diapers $______Pet expenses $______</p><p>Medical, dental, prescription Alimony paid to former spouse $______(out of pocket/uncovered expenses) $______Child support paid for other Grooming, hygiene $______children $______</p><p>Gifts from children to others $______Date of initial order: ______</p><p>Entertainment $______Other (attach sheet) $______</p><p>Activities (including extra-curricular, $______school, religious, cultural, etc.)</p><p>Summer Camps $______</p><p>OTHER INSURANCE Health $______Child(ren)’s portion: $______Dental $______Child(ren)’s portion: $______Vision $______Child(ren)’s portion: $______Life $______Relationship of Beneficiary: ______Disability $______</p><p>Other(specify): $______TOTAL ABOVE EXPENSES $ ______</p><p>6 B. PAYMENTS TO CREDITORS (please check one) To Whom: Balance Due Monthly Joint Plaintiff Defendant Payment</p><p>TOTAL MONTHLY PAYMENTS TO CREDITORS: $ ______</p><p>C. TOTAL MONTHLY EXPENSES: $ ______</p><p>This ______day of ______, 20______.</p><p>______Notary Public Affiant</p><p>7 Rule 24.4. Temporary hearing, scheduling. </p><p>RESERVED. (Former Rule 24.4 is now incorporated in Rule 24.2).</p><p>8</p>