Form Dr 7.3 - Affidavit Of Income, Expenses And Financial Disclosure Form - Court Of Common Pleas, Ohio Page 3

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C. MONTHLY INSTALLMENT PAYMENTS
(Do not list expenses previously listed in Section B)
Balance
Monthly
To Whom Paid
Purpose
Due
Payment
_____________________________________
_____________________________
____________________
$ __________________
_____________________________________
_____________________________
____________________
$ __________________
_____________________________________
_____________________________
____________________
$ __________________
_____________________________________
_____________________________
____________________
$ __________________
MONTHLY TOTAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . .. . $
(C)
GRAND TOTAL MONTHLY EXPENSE (Sum A,B,C, plus D (optional))
$
SECTION III
FINANCIAL DISCLOSURE
A. List all funds on deposit in any and all accounts, in any bank, savings & loan, credit union, regulated investment company, mutual fund or other
financial institution. Account includes ant of the following: checking, certificate of deposit (“CD”), investment, savings, individual retirement
(“IRA”), stock option, etc. Attach additional pages if needed.
Name & Address of
Balance Date of
Financial Institution
Account No.
Name(s) on Account
this Affidavit
_____________________________________
____________________ _________________________________
$ __________________
_____________________________________
_____________________________________
____________________ _________________________________
$ __________________
_____________________________________
B. Other income source listed in Section I (i.e., retirement / pension benefits, disability income, interests dividend income, rentals, annuities, etc. not
listed in Section III-A). Attach additional pages if needed, Need not complete pre-decree.
Identifying Description
Name & Address of Source
(Account No., Claim No. , etc.)
Income or Benefits
_____________________________________
__________________________________
$ __________________ per _________________
_____________________________________
SECTION IV
OTHER ASSETS AND LUMP SUM INCOME
1. Describe assets of more than $1,000 in value not otherwise listed in this affidavit (equity in real estate, stocks, bonds, other investments, etc.) .
Attach additional pages if needed.
(a) __________________________________________________________________________________________ Value $ _________________
(b) __________________________________________________________________________________________
$ _________________
(c) __________________________________________________________________________________________
$ _________________
2. List any lump sum income (bonus), gifts, inheritance, etc.) in excess of $500, expected to be received within the next six months, not otherwise
listed in this affidavit. Attach additional pages if needed.
Source ________________________________________________________________________________________ Value $ _________________
Address _______________________________________________________________________________________
Affiant state that the information contained herein is complete and accurate to the best of their information, knowledge or belief under penalty of law.
_______________________________________________________
_______________________________________________
Attorney for
Affiant
Plaintiff / Petitioner (1)
Defendant / Petitioner (2)
Sworn to and subscribed on my presence this _________________ day of ___________________________________________, 20 __________.
_______________________________________________________
Notary Public
My commission expires ___________________________________
DR 7.3
(Revised 03/16/2016 )
Pg. 3

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