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Child Support Affidavit of Child Support Payment Form document sample
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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
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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 Support Paid
Names Date of Birth Resides with: 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
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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)
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