IN THE SUPERIOR COURT FOR THE COUNTY OF STATE OF GEORGIA. case No. DOMESTIC RELATIONS FINANCIAL AFFIDAVIT

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1 IN THE SUPERIOR COURT FOR THE COUNTY OF STATE OF GEORGIA Plaintiff v case No. Defendant DOMESTIC RELATIONS FINANCIAL AFFIDAVIT Section 1 Affiant's Name Spouse's Name Date of Marriage Age Age Date of Separation Names and birth dates of children of this marriage Name Date of Birth Resides with Names and birth dates of other children residing with Affiant Name Date of Birth Resides with

2 Section 2: SUMMARY OF AFFIANT'S INCOME AND NEEDS Gross Monthly Income (from item 3A) Net Monthly Income (from Item 3C) Average monthly expenses (from item 5A) Monthly payments to creditors (item 5B) Total Monthly Expenses and Payments Monthly Excess or Shortfall Non-custodial Parent's Monthly Salary Amount of Spousal/Child Support Requested by Affiant Amount of Alimony Requested Health Insurance Premium for Children Total Amount Requested from Other Party

3 Section 3: 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 one 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 expenses required to produce income)attach Sheet itemizing this Income Disability/unemployment/workers' comp. Pension, retirements or annuity payments Social Security Benefits Other public benefits (specify) Spousal/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) TOTAL B: List and describe all benefits of employment, e.g., automobile and/or auto allowance, insurance (auto, life, medical, 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.

4 C: Net monthly income from employment (deducting only state, federal, and FICA taxes) Affiant's Pay Period (i.e. weekly, monthly) Number of exemptions claimed Section 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 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 JointAsset Separate Asset of Husband Separate Asset of Wife Cash Stocks Bonds CDs Money Market Accounts Real Estate Home Other Automobiles a. b. c.

5 Money owed you Retirement/IRA Husband Wife Furniture Jewelry Life Insurance(cash value) Collectibles Bank Accounts a. b. Other Assets: Attach sheet itemizing other assets a. b. c. d. Total Assets Section 5: AVERAGE MONTHLY EXPENSES HOUSEHOLD Mortgage or rent payments Property taxes Insurance Repairs & maintenance Lawn care Pest control

6 Electricity Water Garbage & Sewer Telephone Gas Cable TV Miscellaneous household items Meals outside home Groceries Other AUTOMOBILE Gasoline and Oil Repairs Auto tags & License Insurance CHILDRENS' EXPENSES Child Care School supplies/expenses a) a) b) b) School tuition Lunch money a) a) b) b) Allowance Medical, dental, prescriptions Gifts Clothing/Diapers Grooming/Hygiene Entertainment Activities a) a) b) OTHER INSURANCE Health Life Disability Other (specify) a) a) b) b) AFFIANT'S OTHER MISCELLANEOUS EXPENSES Dry cleaning and laundry Medical/Dental Clothing Prescriptions

7 Affiant's gifts (holidays) Vacations Dues, clubs Child support paid to former spouse Entertainment Publications Religious & Charities Alimony paid to former spouse Miscellaneous TOTAL ABOVE EXPENSES B. Payments to Creditors To Whom Balance Due Monthly Payment

8 TOTAL PAYMENTS TO CREDITORS C. Total Expenses C. TOTAL EXPENSES (from Section 5, "Average Monthly Expenses") HOUSEHOLD AUTOMOBILE CHILDRENS' EXPENSES OTHER INSURANCE AFFIANT'S OTHER MISCELLANEOUS EXPENSES TOTAL EXPENSES Signature of Affiant Sworn to and subscribed before me this day of,. Notary Public

For all types of cases, please complete Part I, attach necessary documents, and have your signature notarized on page 2.

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