Form Dr 7.3 - Affidavit Of Income, Expenses And Financial Disclosure Form - Court Of Common Pleas, Ohio

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COURT OF COMMON PLEAS
DIVISION OF DOMESTIC RELATIONS
HAMILTON COUNTY, OHIO
Enter: ______________________________________
Plaintiff
Date:
Address:
Case No.
File No.
-vs/and-
CSEA No.
Defendant
Judge
Address:
AFFIDAVIT OF INCOME, EXPENSES
AND FINANCIAL DISCLOSURE
STATE OF OHIO, SS:
Now comes _______________________________ affiant herein, and having been duly cautioned and sworn, states that they have been
advised that this affidavit may be used for any or all of the following purposes: (1) to make complete disclosure of affiant’s income, liabilities and
expenses; (2) to assist in determining orders of child support or spousal support when applicable or any changes thereto: and (3) to provide for the
issuance of the appropriate deduction order for support.
Minor and/or Dependent Children of this Marriage:
age
is residing with
age
is residing with
age
is residing with
GROSS YEARLY INCOME
SECTION I
Plaintiff
(1) __________ Yes
___________ No ..........................Employed .......................... __________Yes __________ No
(2)
Defendant
$ _________________ ...................... Actual or Estimate ................... Base Yearly Wages ................... Actual or Estimated ..................... $ ___________________
$ _________________ ........................... Yearly Averages Overtime, Commission & Bonus Income ............................................................. $ ___________________
____________________________________________ .................................... Employer ........................................... _______________________________________
____________________________________________ ............................... Payroll Address ......................................._______________________________________
____________________________________________ ................................ City, State, Zip ....................................... ______________________________________
12
24
26
52 .................................................................... Scheduled Paychecks Per Year ............................................................ 12
24
26
52
$ ____________________ ........................................................................ Unemployment Benefits ............................................................... $ ____________________
$ ____________________ ......................................................................... Workers’ Compensation .............................................................. $ ____________________
Social Security or Other Disability Benefits
$ ____________________ ......................................................................... List Sources in Section D-2 ......................................................... $ ____________________
$ ____________________ ............................................. .......................... Spousal Support Received ........................................................... $ ____________________
Interest / Dividend Income
$ ____________________ ......................................................................List Source in Section D-2 .............................................................. $ ____________________
Public Assistance or
($ ___________________) ................................................................... Income Supplement Security ............................................................ ($ __________________ )
Other Income Received
$ ____________________ ................................................................ List Source in Section III-B ................................................................. $ ____________________
$
............................................................... TOTAL YEARLY INCOME ......................................................
$
______
DR 7.3
(Revised 03/16/2016 )
Pg. 1

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