Form Dr-10 - Affidavit Of Financial Disclosure - In The Common Pleas Court Of Montgomery County, Ohio - 2011 Page 2

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B .
OTHER YEARLY INCOME (Please list all sources of other income in Section E.)
PLAINTIFF/PETITIONER (1)
DEFENDANT/PETITIONER (2)
$
Interest/Dividend Income
$
$
Unemployment Compensation
$
Workers' Compensation, Social Security
$
or Other Disability Benefits
$
Social Security &
$
Pension Income
$
$
Gross Self-Employment Income
$
Ordinary & Necessary Business
$
Expenses
$
C.
OVERTIME, COMMISSION AND BONUSES EARNED:
[Past Three Year History - Year 3 Is Most Recent Year]
Overtime, Commission, Bonuses
Overtime, Commission, Bonuses
20_____ Year 1 $_____________________
20_____ Year 1 $_____________________
20_____ Year 2 $_____________________
20_____ Year 2 $_____________________
20_____ Year 3 $_____________________
20_____ Year 3 $_____________________
D.
OTHER INFORMATION CONCERNING CHILDREN:
PLAINTIFF/PETITIONER (1)
DEFENDANT/PETITIONER (2)
Court Ordered Child Support Payable
$
per year
for Other Child(ren)
$
per year
Who Are Not of this Marriage
Court Ordered Spousal Support Payable
$
per year
to a Spouse(s)
$
per year
Number of Other Minor Child(ren)
Living With You (not children of this
marriage or step-children)
Child Support You Receive for
the Minor Child(ren) You
$
per year
Indicated on Line Above
$
per year
E.
OTHER ASSETS AND LUMP SUM INCOME
1.
Describe income sources listed in Section B (i.e., retirement/pension benefits, disability income, interests or dividend
income, rentals, annuities, etc.) Attach additional pages if needed.
Name & Address
Identifying Description
Income or Benefits
of Source
(Account No., Claim No., Etc.)
2

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