Domestic Relations Financial Affidavit - Pataula Judicial Circuit Page 7
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9AFFIANT’S OTHER EXPENSES:
Dry Cleaning/Laundry
$
Clothing
$
Medical, Dental, Prescriptions
$
(out of pocket/uncovered expenses)
Affiant’s Gifts (special holiday)
$
Entertainment
$
Recreational Expenses (e.g., fitness)
$
Vacations
$
Travel Expenses for Visitation
$
Publications
$
Dues, Clubs
$
Religious and charities
$
Pet Expenses
$
Alimony paid to former spouse
$
Child Support paid for other children
$
Date of Initial Order:
Other (attach sheet)
$
TOTAL OTHER EXPENSES:
$
OTHER INSURANCE:
Health
$
Health: Children’s portion
$
Dental
$
Dental: Children’s portion
$
Vision
$
Vision: Children’s portion
$
Life
$
Relationship of Beneficiary:
Disability
$
Pataula Judicial Circuit
Domestic Relations Financial Affidavit - Revised 2016
Page 7 of 9
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