IN THE SUPERIOR COURT OF COBB COUNTY

STATE OF GEORGIA

, Plaintiff, vs. I, , Defendant

) ) ) ) ) ) ) ) )

No.

DOMESTIC RELATIONS FINANCIAL AFFIDAVIT

1. AFFIANT'S NAME _______________________________ Age__________

Affiant's Social Security No. _____________________________________________

Spouse's Age ______________________________________________________________

Date of Marriage _______ Date of Separation _______

Names and birth dates of children of this marriage:

Name Date of Birth Resides With

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Names and birth dates of children of prior marriage residing with Affiant:

Name Date of Birth

___________________________________________________________________________

___________________________________________________________________________

2. SUMMARY OF AFFIANT'S INCOME AND NEEDS

(a) Gross monthly income (from Item 3A) $_____

(b) Net monthly income (from Item 3C) _____

(c) Average monthly expenses (Item 5A) $_____

Monthly payments to creditors (credit cards, revolving credit, installment

loans, car loans (Item 5B) $_____

Total monthly expenses and payments to creditors (Item 5C) _____

(d) Amount of spousal/child support needed by Affiant $_____

(e) Amount of child support indicated by Child Support Guidelines $_____

3. A. AFFIANT'S GROSS MONTHLY INCOME

(All income must be entered based on monthly average regardless of

date of receipt. Where applicable, income should be annualized.)

Salary $_____

Bonuses, commissions, allowances, overtime, tips and similar $_____

payments (based on past 12-month average or time of

employment if less than 1 year) ATTACH SHEET ITEMIZING THIS

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 THIS

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 in 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 the "value" column. "Value" means what

you feel the item of property would be worth if it were offered for sale.)

Description Value Separate Asset of each spouse

(H) husband (W) wife

Cash $______________ _________________ _________________

Stocks, bonds $______________ _________________ _________________

CD's/Money Market Accounts $______________ _________________ _____________

Real estate: home $______________ _________________ _________________

other $______________ _________________ _________________

Automobiles $______________ _________________ _________________

Money owed you $______________ _________________ _________________

Retirement/IRA $______________ _________________ _________________

Furniture/furnishings $______________ _________________ _________________

Jewelry $______________ _________________ _________________

Life insurance (cash value) $______________ _________________ _________________

Collectibles $______________ _________________ _________________

Bank accounts $______________ _________________ _________________

(List each account) $______________ _________________ _________________

$______________ _________________ _________________

Other assets $______________ _________________ _________________

___________________________ $______________ _________________ _________________

___________________________ $______________ _________________ _________________

TOTAL ASSETS $______________ _________________ _________________

5. A. AVERAGE MONTHLY EXPENSES HOUSEHOLD

Mortgage or rent payments __________

Property taxes __________

Insurance __________

Electricity __________

Water __________

Garbage & sewer __________

Telephone __________

Gas __________

Repairs & maintenance __________

Lawn care __________

Pest control __________

Cable TV __________

Miscellaneous household and grocery items __________

Meals outside home __________

Other __________

AUTOMOBILE

Gasoline and oil __________

Repairs __________

Auto tags and license __________

Insurance __________

CHILDREN'S EXPENSES

Child care __________

School tuition __________

School supplies/expenses __________

Lunch money __________

Allowance __________

Clothing __________

Diapers __________

Medical, dental, prescription __________

Grooming/hygiene __________

Gifts __________

Entertainment __________

Activities __________

OTHER INSURANCE

Health __________

Life __________

Disability __________

Other (specify) __________

AFFIANT'S OTHER EXPENSES

Dry cleaning and laundry __________

Clothing __________

Medical/dental __________

Affiant's gifts (special holidays) __________

Entertainment __________

Vacations __________

Publications __________

Dues, clubs __________

Religious and charities __________

Miscellaneous (attach sheet) __________

Other (attach sheet) __________

Alimony paid to former spouse __________

Child support paid to former spouse __________

TOTAL ABOVE EXPENSES $_________

B. PAYMENTS TO CREDITORS (cars, credit cards, installment loans)

To Whom Balance Due Monthly Payments

________________________________________ _______________ ________________

________________________________________ _______________ ________________

________________________________________ _______________ ________________

________________________________________ _______________ ________________

________________________________________ _______________ ________________

________________________________________ _______________ ________________

Total Monthly Payments to Creditors $_______________

C. TOTAL MONTHLY EXPENSES $_______________

This ________ day of ________, 20___.

________________________________________ _________________________________

Notary Public Affiant