Domestic Relations Financial Affidavit Page 7
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13Allowances
$_________ __________ _________
_________
Clothing
$_________ __________ _________
_________
Cellular telephone
$_________ __________ _________
_________
Medical/dental (out of pocket/
uncovered expenses $_________ __________ _________
_________
Psychiatric/psychological/
counseling (out of pocket/
uncovered expenses) $_________ __________ _________
_________
Prescriptions (out of pocket/
uncovered expenses) $_________ __________ _________
_________
Grooming
$_________ __________ _________
_________
Gifts from children to others $_________ __________ _________
_________
Entertainment
$_________ __________ _________
_________
Toys
$_________ __________ _________
_________
Books/Publications
$_________ __________ _________
_________
Summer camps
$_________ __________ _________
_________
Sports and extracurricular
activities
$_________ __________ _________
_________
Other (attach sheet)
$_________ __________ _________
_________
Sub-total Child(ren) Expenses
$ ______________
INSURANCE
Health
Total
$_________
Child(ren) portion
$_________ __________ _________
_________
Dental
Total
$_________
Child(ren) portion
$_________ __________ _________
_________
Vision
Total
$_________
Child(ren) portion
$_________ __________ _________
_________
Life Insurance on
child(ren)’s life only $_________ __________ _________
_________
Other (specify)
$_________ __________ _________
_________
$ ________________
Sub-total Child(ren)’s Insurance
$ _____________
TOTAL AVERAGE MONTHLY EXPENSES (Section A)
$ _____________
Domestic Relations Financial Affidavit
Fulton County Family Division
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