Domestic Relations Financial Affidavit Page 2
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7Monthly payments to creditors (Item 5B below)
Total monthly expenses & payments to Creditors (Item 5C below)
(3) (A) YOUR GROSS MONTHLY INCOME: (Complete this section or attach Child Support Schedule A. All
income must be entered based on monthly averages regardless of date of receipt. Where applicable, income
should be annualized.)
Salary or Wages - ATTACH COPIES OF 2 MOST RECENT WAGE STATEMENTS
Commissions, Fees & Tips
Income from self-employment, partnership, close corporations and independent contracts
(gross receipts minus ordinary and necessary expenses required to produce income)
ATTACH SHEET ITEMIZING YOUR CALCULATIONS
Rental income (gross receipts minus ordinary and necessary expenses required to produce
income) ATTACH SHEET ITEMIZING YOUR CALCULATIONS
Bonuses
Overtime Payments
Severance Pay
Recurring Income from Pensions or Retirement Plans
Interest and Dividends
Trust income
Income from Annuities
Capital Gains
Social Security Disability or Retirement Benefits
Worker's Compensation Benefits
Unemployment Benefits
Judgments from Personal Injury or Other Civil Cases
Gifts (cash or other gifts that can be converted to cash)
Prizes & Lottery Winnings
Alimony and maintenance from persons not in this case
Assets which are used for support of family
Fringe Benefits (if significantly reduce living expenses)
Any Other Income (Do not included means-tested public assistance, such as TANF or food
stamps.)
TOTAL Gross Monthly Income (also write in 2A on page one)
(3) (B) Net Monthly Income from Employment (deducting only state and federal taxes and
FICA) (also write in 2B on page one)
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