"Child Support Affidavit Form"
Domestic Relations Financial Affidavit Instructions and Disclosure (Please read this document carefully) The attached document is called a Domestic Relations Financial Affidavit, or DRFA, and is required to be completed and filed with the Court in all domestic cases. This form is extremely important to your case and it is imperative that you completely and accurately fill out this document. Accurate completion of this form will expedite the filing process and will prevent additional billing in preparing this document. Some actions cannot even be filed, nor can a hearing be set until the Domestic Relations Financial Affidavit is completed and filed with the court. Therefore, we ask that you thoroughly read this instruction sheet and adhere to the following guidelines in completing the DRFA: 1) Income: Attach your two (2) most recent paystubs. We will use this information to calculate your gross and net monthly income. Please make sure to include any overtime income and income from self-employment on Page 2 of the form. 2) Assets and Monthly Expense: Please do not leave any blanks on this section of the form. If the amount you pay for a certain item is zero, then indicate this by placing a zero in that cell. For example, if you do not own any real property or vehicles (you will find this on Page 3), please place a zero in the appropriate cell. If you do own real property or vehicles, please indicate the fair market value and the debt owed for each item in the appropriate cells. We request that you follow these same guidelines throughout the Asset and Monthly Expense sections while completing the DRFA. Please note that the affidavit asks for your monthly expenses. Therefore, be sure to divide by 12 expenses such as auto tags which you usually pay annually and insert that figure on the affidavit. Also, if your property taxes and property insurance are included in your monthly mortgage payment, you may indicate that $.00 is paid monthly in these spaces. Please note that there is a separate portion for child related expenses in this section and we request that you keep this in mind when completing this form. However, there is a space on the affidavit for travel visitation expenses, which is not inclusive in the child related expenses 3) Child Related Expenses: We need an accurate monthly figure of your child care expenses, extraordinary educational expenses, etc. It is extremely important that we have accurate amounts for this expense, as you may receive a credit for this amount on the Child Support Worksheet. 4) Medical Insurance: Please complete this section to the best of your ability and be sure to indicate the monthly amount paid, if any, for children’s medical insurance premium in the appropriate cell. These amounts should match the deduction on your paycheck stub if your premium is paid through your employer. Please follow these same guidelines when entering the amounts paid for dental, vision and life insurance. Again, it is extremely important that we have accurate amounts for these items, as you may receive credits for these amounts on the Child Support Worksheet. 5) Monthly Payments to Creditors: This section should include an itemized list of all debts and payments to creditors, with the exception of your mortgage payment, which is already listed in the Monthly Expense section. Include the name of the creditor, the balance owed and the monthly payment for all debts, including credit cards, car payments, etc. **Your cooperation in getting this information to us, although time consuming, is essential to the proper preparation of your case.** __________________________________________________________________ Disclosure of Income, Assets, and Expenses I, _________________________, hereby affirm that the figures and facts set forth in the attached Domestic Relations Financial Affidavit are true and correct. I further state that I have made a full disclosure of my income, expenses, and all assets, both marital and pre-marital, including real and personal property, to my attorney, as set forth on this form. This ___ day of _________________, 200___. Signed by: __________________________ (Affiant) Form #: FL103 Revised 12/2009 D:\Docstoc\Working\pdf\59b00971-782f-4939-adce-93c7fe6e9781.xls Page 2 of 7 IN THE SUPERIOR COURT OF COUNTY STATE OF GEORGIA ) ) Plaintiff ) vs. ) CIVIL ACTION NO. ) Defendant ) DOMESTIC RELATIONS FINANCIAL AFFIDAVIT 1 AFFIANT'S NAME: Age Spouse's or Other Parent's Name: Age Date of Marriage: Date of Separation: Names and birth dates of children for whom support is to be determined in this action: Names Date of Birth Resides with: Names and birth dates of Affiant's other children, (exclude step children): Date of Initial Support Paid Names Date of Birth Resides with: Support Order by Affiant 2 SUMMARY OF AFFIANT'S INCOME AND NEEDS: (a) Gross monthly income (Item 3A) $0.00 (b) Net monthly income (Item 3B) $0.00 (c) Average monthly expenses (Item 5A) $0.00 (d) Monthly payments to creditors (Item 5B) $0.00 (e) Total monthly expenses/payments to creditors (Item 5C) $0.00 Page 3 of 7 3 A. AFFIANT'S GROSS MONTHLY INCOME (complete this section or attach Child Support Schedule A) (All income must be entered based on monthly average regardless of date of receipt.) Salary or Wages ATTACH COPIES OF 2 MOST RECENT WAGE STATEMENTS Commissions, Fees, Tips Income from self-employment, partnership, close corporations, and independent contractors (gross receipts minus ordinary and necessary expenses required to produce income) ATTACH SHEET ITEMIZING YOUR CALCULATIONS Rental Income (gross receipts minus ordinary and necessary expenses required to produce income) ATTACH SHEET ITEMIZING YOUR CALCULATIONS Bonuses Overtime Payments Severance Pay Recurring Income from Pensions or Retirement Plans Interest and Dividends Trust Income Income from Annuities Capital Gains Social Security Disability or Retirement Benefits Workers' Compensation Benefits Unemployment Benefits Judgments from Personal Injury or Other Civil Cases Gifts (cash or other gifts that can be converted to cash) Prizes/Lottery Winnings Alimony and maintenance from persons not in this case Assets which are used for support of family Fringe Benefits (if significantly reduces living expenses) Any other income (do NOT include means-tested public assistance, such as TANF or food stamps) GROSS MONTHLY INCOME $0.00 Page 4 of 7 B. Affiant's net monthly income from employment (deducting only State and Federal Taxes, Social Security and Medicare withholdings) Gross Monthly Income $0.00 State Income Taxes Federal Income Taxes FICA Social Security Tax FICA Medicare Tax Net Monthly Income: $0.00 Affiant's pay period (i.e. weekly, bi-weekly, monthly, bi-monthly): Number of tax exemptions claimed on IRS Form W-4 or tax return: 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 and state the amount and the basis: pre-marital (PM), gift (G), inheritance (INH), source of funds (SoF), etc.). Separate Asset of Separate Asset of Basis of the Description Value the Husband the Wife Claim Cash Stocks, bonds CD's/Money Market Accounts Bank Accounts (list each account): Retirement Pensions, 401K, IRA, or Profit Sharing Money owed you: Tax Refund owed you: Real Estate: Home: debt owed: other: debt owed: Automobiles/Vehicles: Vehicle 1: debt owed: Vehicle 2: debt owed: Page 5 of 7 Life Insurance (net cash value): Furniture/furnishings: Jewelry: Collectibles: Other Assets (List): Total Assets: $0.00 $0.00 $0.00 5 A. AVERAGE MONTHLY EXPENSES: HOUSEHOLD Mortgage or rent payments Cable TV Property taxes Misc. household and grocery items Homeowner/Renter Insurance Meals outside the home Electricity Other household expenses: Water AUTOMOBILES Garbage and Sewer Gasoline and oil Telephone: Repairs residential line: Auto tags and license cellular telephone: Insurance Internet Service OTHER VEHICLES Gas (boats, trailers, RVs, etc.) Repairs and maintenance Gasoline and oil Lawn Care Repairs Pest Control Tags and license Insurance Page 6 of 7 CHILDREN'S EXPENSES AFFIANT'S OTHER EXPENSES Regular child care Dry cleaning/laundry Special Care (non-school periods) Clothing Tutoring Medical, dental, prescription (out of pocket/uncovered expenses) Private lessons (e.g.,music, dance) School tuition Affiant's gifts (special holidays) School Supplies/expenses Entertainment Lunch Money Recreational Expenses (e.g., fitness, golf, bowling) Other Educational Expenses (list): Vacations Travel Expenses for Visitation Allowance Publications Clothing Organizations dues, clubs, etc. Baby Formula Religious and charities Diapers Pet expenses Medical, dental, prescription (only out of pocket/uncovered expenses) Alimony paid to a former spouse Grooming, hygiene Personal Educational Expenses Gifts (from children to others) Other Expense (attach sheet) Other: Other: Other: Entertainment Child support paid for another child Activities (e.g. extra-curricular, sports, religious, cultural, etc.) Date of initial order: Summer Camps Name of child OTHER INSURANCE Child support paid for another child Health Insurance Premiums Date of initial order: Child(ren)'s portion: Name of child Dental Insurance Premiums Child support paid for another child Child(ren)'s portion: Date of initial order: Vision Insurance Premiums Name of child Child(ren)'s portion: Life Insurance Premiums Disability Relationship of Beneficiary: Retirement Contribution: TOTAL ABOVE EXPENSES $0.00 Page 7 of 7 B PAYMENTS TO CREDITORS: (Place an "X" in the column for whom is to pay this debt.) To Whom: Balance Due Monthly Payment Joint Plaintiff Defendant TOTAL MONTHLY PAYMENTS TO CREDITORS: $0.00 X C TOTAL MONTHLY EXPENSES AND PAYMENTS TO CREDITORS: $0.00 Other/ Comment/ Explanation: Page 8 of 7 Superior Juvenile Page 9 of 7 Page 10 of 7 Page 11 of 7 Page 12 of 7 Page 7 of 7 VERIFICATION The Undersigned Affiant does state under oath (or affirmation) that the information contained in the foregoing Domestic Relations Financial Affidavit is true, correct, and current as of the date of this Verification. Affiant: 0 Sworn to before me this Day of ,20 Notary Public (Seal)