Form Dr 7.3 - Affidavit Of Income, Expenses And Financial Disclosure Form - Court Of Common Pleas, Ohio Page 2
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1
2
3
4Husband (1)
Wife (2)
ANNUAL INCOME, OVERTIME AND BONUSES EARNED
(Past Three Years)
Overtime,
Overtime
and/or
and/or
Base Income
Bonuses
Base Income
Bonuses
_________ year 3 . . . . . . . . $ __________
$___________
________ year 3 . . . . . . . $ _____________
$ _______________
_________ year 2 . . . . . . . . $ __________
$___________
MOST
________ year 2 . . . . . . . $ _____________
$ ________________
RECENT
_________ year 1 . . . . . . . . $ __________
$___________
YEAR
________ year 1 . . . . . . . $ _____________
$ ________________
ADJUSTMENTS
Court Ordered Support Paid
$ ____________________ per year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . for other child(ren) . . . . . . . . . . . . . . . . . . . . . . . . . . . $ ____________________ per year
Court Ordered Spousal Support
Paid to a Former Spouse
$ ____________________ per year . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . $ ____________________ per year
Number of Other Dependent
_____________________________ . . . . . . . . . . . . . . . . . . . . . . . . .Children living with the Party. . . . . . . . . . . . . . . . . . . . . . . . . ____________________________
(Excluding Unadopted Step Children)
Child Support Received for Other Dependent Children
$ ____________________ per year . . . . . . . . . . . . . . . . . . . . . . . . . . . Indicated Immediately Above. . . . . . . . . . . . . . . . . . . . . . . . $ ____________________ per year
Health Insurance Premium Paid
$ ____________________ per year . . . . . . . . . . . . . . . . . . . . . . . . . . by Party if Children Included. . . . . . . . . . . . . . . . . . . . . . . . . $ ____________________ per year
For Post Decree Modifications Only
Gross Income of Current Spouse or
$ ____________________ per year . . . . . . . . . . . . . . . . . . . . . . . . . . Other Contributor in Household. . . . . . . . . . . . . . . . . . . . . . . $ ____________________ per year
SECTION II
AFFIANT’S MONTHLY EXPENSES
List expenses below for your present household. There are
adults and
children in my household.
A. Housing:
1. Rent or Mortgage (including taxes and insurance) ....................................................................................................
$
2. Utilities
a. Gas & Electric
................................................................................................................ $
b. Water & Sewer
................................................................................................................ $
c. Telephone (excluding long distance) ................................................................................................................ $
d. Trash Collection
................................................................................................................ $
e. Cable Television
................................................................................................................ $
3. Other ..................................................................................................................................................................... $ _____________
..................................................................................................................................................................... $ _____________
TOTAL HOUSING........................................................................................................................................................ $
(A)
B.
Other
1. Car Repairs and License . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..... $ _____________
2. Insurance: _________________________ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... $ _____________
3. Medical Expenses (not covered by insurance) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... $ _____________
4. Clothing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...... $ _____________
5. Grocery Items (to include food, laundry and cleaning products/toiletries, etc.) . . . . . . . . . . . . . . . . . . . . . . . . . . .... $ _____________
6. Child Related Expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..... $ _____________
a. (employment related only) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . .. . . . ..... $ _____________
b. Other _____________________________ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... $ _____________
7. Gasoline & Oil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..... $ _____________
8. Other: _________________________________________________________ . . . . . . . . . . . . . . . . .. . . . . . . . . . . $ _____________
MONTHLY TOTAL ....................................................................................................................................................... $
(B)
DR 7.3
(Revised 03/16/2016 )
Pg. 2
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