Domestic Relations Financial Affidavit - Georgia Family Division Page 7
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13Psychiatric/psychological/
counseling (out of pocket/
uncovered expenses)
$_________ __________ _________
_________
Prescriptions (out of pocket/
uncovered expenses)
$_________ __________ _________
_________
Grooming
$_________ __________ _________
_________
Gifts from children to others $_________ __________ _________
_________
Entertainment
$_________ __________ _________
_________
Toys
$_________ __________ _________
_________
Books/Publications
$_________ __________ _________
_________
Summer camps
$_________ __________ _________
_________
Sports and extracurricular
activities
$_________ __________ _________
_________
Other (attach sheet)
$_________ __________ _________
_________
Sub-total Child(ren) Expenses
$ ______________
INSURANCE
Health
Total
$_________
Child(ren) portion
$_________ __________ _________
_________
Dental
Total
$_________
Child(ren) portion
$_________ __________ _________
_________
Vision
Total
$_________
Child(ren) portion
$_________ __________ _________
_________
Life Insurance on
child(ren)’s life only
$_________ __________ _________
_________
Other (specify)
$_________ __________ _________
_________
________________________
Sub-total Child(ren)’s Insurance
$ _____________
TOTAL AVERAGE MONTHLY EXPENSES (Section A)
$ _____________
B.
PAYMENTS TO CREDITORS
Account #
Monthly
To Whom
(last 4 digits) Balance Due Payments
Name(s)on Account
_______________
__________ ___________ __________ _________________
_______________
__________ ___________ __________ _________________
_______________
__________ ___________ __________ _________________
_______________
__________ ___________ __________ _________________
_______________
__________ ___________ __________ _________________
_______________
__________ ___________ __________ _________________
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