Free - Ohio

DR 602A Rev. 8/05

IN THE COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS BUTLER COUNTY, OHIO Judge Sharon L. Kennedy Judge Eva D. Kessler Case No. ___________________

_____________________________________ Plaintiff/1st Petitioner/Petitioner DOB ________________________________ Address ______________________________ ______________________________ V. _____________________________________ Defendant/2nd Petitioner/Respondent DOB ________________________ Address

Affidavit of Income ______________________
(Name of Affiant) Date of Marriage __________________ Date of Separation_________________

______________________
_____________________________

Note: This affidavit must be completed and exchanged in accordance with Local Rules of Court in every action for divorce, dissolution, legal separation, annulment and post decree motion that concerns modification of support. You will be required to provide proof of income per local rule and O.R.C. 3121. You are under a continuing legal duty to file an updated version of this form if you learn of any additional information. If more space is needed, attach additional page(s).

I. Income [As defined in O.R.C. 3119.01(C)]:
A. Gross Yearly Income from Employment
(If not known, please estimate. Put "EST" after each estimated figure.)

Husband / Father
Gross Yearly Employment Income Employer Address of Employer City, State, Zip Check the number of Paychecks per year Year-to-date Gross Income Prior Year's Tax Refund

Wife / Mother

12

24

26

52

12

24

26

52

Through date of

Through date of

Initialed

Income Affidavit Page 1

B. Annual Overtime, Commissions, Bonuses
(If not known, please estimate. Put "EST" after each estimated figure.)

Husband / Father
Year 3 is Most Recent Year 20 20 20 Year 1 Year 2 Year 3 Base Income Overtime, Commission, Bonuses 20 20 20 Year 3 is Most Recent Year Year 1 Year 2 Year 3

Wife / Mother
Base Income Overtime, Commission, Bonuses

Y-T-D This Year Through:_____

Y-T-D This Year Through: _______

C. Gross Self-Employment Income
(If not known, please estimate. Put "EST" after each estimated figure.)
Use Gross Annual Figures for Most Recent Full Year. See O.R.C. 3119.01(C)

Husband / Father

Wife / Mother

Business Receipts Ordinary & Necessary Business Expenses Net Business Income

D. Other Income
All other income, actual or expected, including pension, social security, workers compensation, commissions, royalties, disability benefits, trust income, annuities, recurring capital gains, unemployment benefits, rents, expense-sharing, dividends, interest, AFDC, SSI, food stamps, spousal support received from a prior spouse, etc. (If not known, please estimate. Put "EST" after each estimated figure.)

Husband / Father
Per Year Describe Per Year

Wife / Mother
Describe

E. Total Annual Income Husband / Father
Total gross annual income Total average gross monthly income ÷ 12 =

Wife / Mother
Total gross annual income Total average gross monthly income ÷ 12 =

Initialed

Income Affidavit Page 2

Less Average monthly deductions Total net monthly income = Average monthly deductions Total net monthly income

Less

=

F. Benefits of Employment
(Use of company car, country club memberships, stock options, etc.)

Husband / Father
Benefits Values Benefits

Wife / Mother
Values

II. Information Required for Support Calculation:
A. Minor or Dependent Children of this Marriage
Child's Name Date of Birth Residing with

B. Other Minor Children Living in My Household
Child's Name Date of Birth Relationship

C. Other Minor Children of Mine, Not Living in My Household
Child's name Date of Birth Residing with

OATH OF AFFIANT (print) hereby swear or affirm that the information set forth in this I, Affidavit of Income above is true, complete, and accurate. I understand that falsification of this document may result in a contempt of court finding against me which could result in a jail sentence and fine, and that falsification of this document may also subject me to criminal penalties for perjury (O.R.C. 2921.22).
AFFIANT Sworn to and subscribed before me this Day of , .

Notary Public

Initialed

Income Affidavit Page 3