Domestic Relations Financial Affidavit Page 3
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6Any other income
(do NOT include means-tested Public
assistance, such as TANF or food stamps)
GROSS MONTHLY INCOME
Affiant's Net Monthly Income from employment
3B.
(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 and state the amount and the basis: pre-marital, gift, inheritance, source of
funds, etc.)
Separate Asset
Separate Asset
Basis of the Claim
Description
Value
of Husband
of Wife
Cash:
Stocks, bonds:
CD's/Money
Market Accounts:
Bank accounts (list
each account):
Retirement
Pensions, 401K,
IRA, or Profit
Sharing:
Money owed you:
Tax refund owed you:
Real Estate:
home:
debt owed:
other:
debt owed:
Domestic Relations Financial Affidavit
Page 3 of 6
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