Domestic Relations Financial Affidavit - 2017 (Page 2 of 5) in pdf

Domestic Relations Financial Affidavit - 2017 Page 2

on past 12-month average or time of employment if less than 1 year)

ATTACH SHEET ITEMIZING INCOME

Business income from sources such as self-employment, partnership, close

corporations and/or independent contracts (gross receipts minus ordinary and

necessary expenses required to produce income)

ATTACH SHEET ITEMIZING INCOME

Disability/unemployment/worker’s compensation

Pension, retirements, or annuity payments

Social security benefits

Other public benefits (specify)

Spousal or child support from prior marriage

Interest and dividends

Rental income (gross receipts minus ordinary and necessary expenses required

to produce income.

ATTACH SHEET ITEMIZING THIS INCOME

Income from royalties, trusts or estates

Gains derived from dealing a property (not including non-recurring gains)

Other income of a recurring nature (specify source)

GROSS MONTHLY INCOME

B. List and describe all benefits of employment, e.g., automobile and/or auto

allowance, insurance (auto, life, disability, etc) deferred compensation,

employer contribution to retirement or stock, club memberships and reimbursed

expenses (to the extent they reduce personal living expenses) ATTACH SHEET,

IF NECESSARY.

C. Net monthly income from employment (deducting only state and federal

taxes and FICA)

Affiant’s pay period (i.e., weekly monthly, etc)

Number of exemptions claimed

4. ASSETS

(If you claim or agree that all or part of an asset is non-marital, indicate the non-marital

portion under the appropriate spouse's column. The total value of each asset must be listed in

Domestic Relations Financial Affidavit - 2017 Page 2