Domestic Relations Financial Affidavit Page 4
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13B.
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
st
1
Mortgage
$ ______________
nd
Mortgage
$ ______________
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Domestic Relations Financial Affidavit
Fulton County Family Division
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