Bcpc Form 523 - Affidavit Of Income And Expenses - Butler County, Ohio

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PROBATE COURT OF BUTLER COUNTY, OHIO
RANDY T. ROGERS, JUDGE
GUARDIANSHIP OF
, A MINOR
CASE NO.
AFFIDAVIT OF INCOME AND EXPENSES
STATE OF OHIO, COUNTY OF BUTLER, SS:
Now comes ____________________ parent/guardian of __________________
(Name of Affiant)
(Name of Minor)
who being duly sworn and cautioned, states as follows:
1.
I am requesting the release of $ ______________ from the funds on deposit at
_____________________ held in the name of _________________________.
2.
The purpose of the request for the release of funds is:
________________________________________________________________
________________________________________________________________
3.
My marital status is _____________________ and the number of members in
my household is _____ .
4.
I am employed with ___________________________________ and my annual
salary is $ ______________ .
5.
I state that my spouse is employed with ____________________________ and
his/her annual salary is $ __________ .
6.
My current monthly household expenses are as follows:
Mortgage/Rent
$ _______________
Utilities
$ _______________
Food
$ _______________
Clothing
$ _______________
Medical
$ _______________
Installment Loans
$ _______________
Credit Cards
$ _______________
Insurance
$ _______________
Child Support
$ _______________
Spousal Support
$ _______________
0.00
TOTAL EXPENSES $ _______________
BCPC FORM 523 - AFFIDAVIT OF INCOME AND EXPENSES
Page 1 OF 2
7/1/04

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