Form Dr-10 - Affidavit Of Financial Disclosure - In The Common Pleas Court Of Montgomery County, Ohio - 2011

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IN THE COMMON PLEAS COURT OF MONTGOMERY COUNTY, OHIO

DR-10 (1-11)

DIVISION OF DOMESTIC RELATIONS

CASE NO.

PLAINTIFF/PETITIONER (1)

Address:

SETS NO.

CROSS / WOOD

JUDGE:

DOB:

-vs- / -and-

AFFIDAVIT OF FINANCIAL DISCLOSURE

(MONT. D. R. RULE 4.10)

DEFENDANT/PETITIONER (2)

Address:

DOB:

STATE OF OHIO, SS:

Now comes _______________________________, affiant herein, and having been duly cautioned and sworn, states that

he/she has 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 support when applicable.

TEMPORARY ORDERS/OTHER ACTIVE CASES:

I do not request a temporary order.

I request a temporary order for ___________ custody, ___________ child support, and/or _____________ spousal support.

A Domestic Violence Order under Case No. ________________________________________________ currently is in effect.

A UIFSA or Juvenile Court Case under Case No. ____________________________________________ currently is in effect.

A Bankruptcy action under Case No. _______________________ was filed ________________________________________.

DATE OF SEPARATION (NEW CASES)

______________________________________

II.

MINOR AND/OR DEPENDENT CHILDREN ONLY OF THIS MARRIAGE:

___________________________________________DOB:____________________Residing with_________________________________

EMPLOYMENT OR SCHOOL RELATED CHILD CARE EXPENSES FOR THESE CHILDREN: $_______________________per year

III.

TOTAL INCOME FROM ALL SOURCES, (A, plus B, plus Average of C)

PLAINTIFF $__________________________

DEFENDANT

$__________________________

GROSS YEARLY INCOME FROM EMPLOYMENT

PLAINTIFF/PETITIONER (1)

DEFENDANT/PETITIONER (2)

______ YES ______ NO ................................................... Employed? ........................................................______YES ______NO

...... (Actual or Estimate)........Base Yearly Wages........(Actual or Estimate)

or Gross Receipts if Self-Employed

.......................... Employer ..........................

..................... Payroll Address .....................

......................City, State, Zip......................