CIRCUIT COURT FOR THE TWENTY-THIRD JUDICIAL CIRCUIT
KENDALL COUNTY, ILLINOIS
Case Number_____________
Petitioner: ________________________________________
Respondent: ______________________________________
AFFIDAVIT OF INCOME & EXPENSES
A. Name: ____________________________________________________ B. Date of Marriage: ____________________
C. Children of the Parties (names & ages): ________________________________________________________________
________________________________________________________________________________________________________
D. Custodial Parent: _______________________________________ E. Are Parties Separated? ___________________
F. Monthly Income (if paid weekly, multiply by 52 and divide by 12 to get monthly figures):
Place of Employment:________________________________________________ Monthly Gross: _________________
Federal Income Tax: ____________________ State Income Tax: _________________ F.I.C.A.: ________________
Other Involuntary Deductions (specify): _______________________________________________________________
Voluntary Deductions (specify): _______________________________________________________________________
Number of Exemptions Claimed: ________ Income from other Sources (specify): ___________________________
________________________________________________ Monthly Net Income: ________________________________
G. Cash on Hand (savings, checking, etc.): ________________________________________________________________
________________________________________________________________________________________________________
H. Basic Household Monthly Expenses:
1.
Rent or Mortgage:___________________
11. Car Insurance: ___________________________
2.
House/Renters Ins. _________________
12. Child Care: ______________________________
3.
Real Estate Taxes: __________________
13. Education (specify): _______________________
4.
Gas (house): ________________________
14. Food:_____________________________________
5.
Electric: ___________________________
15. Medical/Dental: __________________________
6.
Water/Garbage: ____________________
16. Clothing: _________________________________
7.
Telephone: _________________________
17. Other Ins. (specify): _______________________
8.
Car: Plates/sticker/repair: ___________
18. Recreation & Travel: ______________________
9.
Gas (car): __________________________
19. Cosmetic/Drugs/Beauty Care: ______________
10. Car Payment:_______________________
20. Other monthly creditor payments (specify creditor, balance & monthly payments
Miscellaneous (specify):
21.
TOTAL:
_____________
STATE OF ILLINOIS
} SS
COUNTY OF KENDALL
Under penalties as provided by law pursuant to Section 1-109 of the Code of Civil Procedure, the undersigned certifies that
the statements set forth in this instrument are true and correct, except as to matters therein stated to be on information and
belief and as to such matters the undersigned certifies that he/she verify believes the same to be true
DATE: __________________________________
__________________________________________________
Signature of Party
10/13
CC10