GA Financial Affidavit
Superior Court of ________County, Georgia
)
______________________,
Plaintiff )
)
vs. ) Civil Action No. ___________
)
______________________, )
Defendant )
)
DOMESTIC RELATIONS FINANCIAL AFFIDAVIT
1. AFFIANT’S NAME:_______________ Age _________
Spouse’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:
Name Date of Birth Resides with
________________________________________________________
________________________________________________________
________________________________________________________
Names and birth dates of affiant’s other children:
Name Date of Birth Resides with
________________________________________________________
________________________________________________________
________________________________________________________
2. SUMMARY OF AFFIANT’S INCOME AND NEEDS
(a) Gross monthly income (from item 3A) $ ______________
(b) Net monthly income (from item 3B) ______________
(c) Average monthly expenses (item 5A) $ ______________
Monthly payments to creditors + ______________
Total monthly expenses and payments
to creditors (item 5C) _______________
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 contracts (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 reduce living expenses) $ ______________
Any other income (do NOT include means-tested
Public assistance, such as TANF or food stamps) $ _____________
GROSS MONTHLY INCOME $ ______________
B. Affiant’s 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 and state the amount and the basis: pre-marital, gift, inheritance, source of funds, etc.).
Description Value Separate Asset
of the Husband Separate Asset
of the Wife Basis of the
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: $____________
$____________ ______________ ______________ ____________________
Life Insurance
(net cash value):
$____________
______________
______________
____________________
Furniture/furnishings:
$____________
______________
______________
____________________
Jewelry:
$____________
______________
______________
____________________
Collectibles:
$____________
______________
______________
____________________
Other Assets:
$____________
______________
______________
____________________
_______________
$____________
______________
______________
____________________
_______________
$____________
______________
______________
____________________
_______________
$____________
______________
______________
____________________
Total Assets:
$____________
______________
______________
____________________
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
$ __________
Water
$ __________
AUTOMOBILE
Garbage and Sewer
$ __________ Gasoline and oil $ __________
Telephone:
residential line:
cellular telephone:
$ __________
$ __________ Repairs
Auto tags and license
Insurance $ __________
$ __________
$ __________
Gas
$ __________
OTHER VEHICLES
(boats, trailers, RVs, etc.)
Repairs and maintenance:
$ __________ Gasoline and oil $__________
Lawn Care
$ __________ Repairs $__________
Pest Control
$ __________ Tags and license
Insurance $__________
$__________
CHILDREN’S EXPENSES AFFIANT’S OTHER EXPENSES
Child care (total monthly cost)
$__________
Dry cleaning/laundry
$__________
School tuition
$__________
Clothing
$__________
Tutoring
$__________
Medical, dental, prescription
(out of pocket/uncovered expenses)
$__________
Private lessons (e.g., music, dance) $__________
Affiant’s gifts (special holidays)
$__________
School supplies/expenses
$__________
Entertainment
$__________
Lunch Money
$__________
Recreational Expenses (e.g., fitness)
$__________
Other Educational Expenses (list)
Vacations
$__________
____________________
$__________
Travel Expenses for Visitation
$__________
____________________
$__________
Publications
$__________
Allowance
$__________
Dues, clubs
$__________
Clothing
$__________
Religious and charities
$__________
Diapers
$__________
Pet expenses
$__________
Medical, dental, prescription
(out of pocket/uncovered expenses)
$__________
Alimony paid to former spouse
$__________
Grooming, hygiene
$__________ Child support paid for other children
$__________
Gifts from children to others
$__________
Date of initial order:
__________
Entertainment
$__________
Other (attach sheet)
$__________
Activities (including extra-curricular,
school, religious, cultural, etc.)
$__________
Summer Camps
$__________
OTHER INSURANCE
Health
Child(ren)’s portion: $__________ $__________
Dental
Child(ren)’s portion: $__________ $__________
Vision
Child(ren)’s portion: $__________ $__________
Life
Relationship of Beneficiary: $__________
____________
Disability $__________
Other (specify):
$__________
TOTAL ABOVE EXPENSES $ _______________________
B. PAYMENTS TO CREDITORS
(please check one)
To Whom: Balance Due Monthly Payment Joint Plaintiff Defendant
TOTAL MONTHLY PAYMENTS TO CREDITORS: $ ___________________
C. TOTAL MONTHLY EXPENSES: $ ______________________
This ______________________ day of ___________, 20________.
_____________________________________
Affiant’s Signature
_____________________________________
Notary Public Affiant
