IN THE CIRCUIT COURT FOR
COUNTY, (STATE)

	CASE NO.:
	AFFIDAVIT OF INCOME AND EXPENSES
Petitioner,	AFFIDAVIT OF INCOME AND EXPENSES
vs.

Respondent.

,
the Petitioner/Respondent hereinafter called Wife/Husband, being first duly sworn, upon oath, respectfully represents to the Court that:

The parties were married on ; the Wife's age is ; the Husband's age is .
The parties have been separated months during which the Husband/Wife has paid $ to the Wife/Husband.
(a) There are              children of the parties, aged
                                              , now in the care of the Wife/Husband at                                                                         .
(b) The family home is owned/rented by the parties and is now occupied by the Wife/Husband or both parties and
                                                                                                     .
(c) For the best interest of the minor children, they should be in the temporary custody of the Husband/Wife.
(d) The Wife has              minor children from a prior marriage. The amount of support received/paid is $                     per month.
(e) The Husband has              minor children from a prior marriage. The amount of support received/paid is $                     per month.

This is not a substitute for legal advice. An attorney must be consulted.
Copyright © 1994 - 2015 by LAWCHEK, LTD.

APPROXIMATE MARKET VALUE AND ENCUMBRANCES

(a) Rent	$	$
(b) Mortgage Payment	$	$
(c) Contract for Deed Payment	$	$
(d) Homeowner's Insurance	$	$
(e) Real Estate Taxes	$	$
(f) Utilities	$	$
(g) Heat	$	$
(h) Food	$	$
(i) Clothing	$	$
(j) Laundry/Dry Cleaning	$	$
(k) Medical/Dental	$	$
(l) Transportation/Car Payment	$	$
(m) Car Insurance	$	$
(n) Life Insurance	$	$

This is not a substitute for legal advice. An attorney must be consulted.
Copyright © 1994 - 2015 by LAWCHEK, LTD.

(o) Recreation/Entertainment/Travel	$	$
(p) Newspapers/Magazines	$	$
(q) Social/Church Obligations	$	$
(r) Personal Allowances/Incidentals	$	$
(s) Babysitting/Child Care	$	$
(t) Home Maintenance	$	$
(u) Children's Needs/Allowances	$	$
(v) Additional Information regarding debts and expenses:
	$	$
	$	$
	$	$
TOTAL:	$	$

EMPLOYMENT DATA: Provide the following data for each employer, and attach prior month's paycheck stub(s) as Exhibit.

		HUSBAND	WIFE
(a)	Name of Employer
	Type of Employment
(b)	Income:
1. Gross income per*		$	$
2. Statutory Deductions:
Federal Income Tax		$	$
State Withholding		$	$
Social Security (FICA)		$	$
Pension Deductions		$	$
Union Dues		$	$
Dependent Health and Hospitalization Coverage		$	$
Dental Coverage		$	$
3. Subtotal of Statutory Deductions		$	$
4. Net Income (lines 1 - 3)		$	$
5. Other Paycheck Deductions:
Specify:		$	$
		$	$
6. Subtotal: (Other Deductions)		$	$
7. NET TAKE-HOME PAY (lines 4-6)		$	$

This is not a substitute for legal advice. An attorney must be consulted.
Copyright © 1994 - 2015 by LAWCHEK, LTD.

(c)	Tax withholding figures above are based on married or single taxpayers with # deductions (Example:M-4 or S-2):	$	$
(d)	Employer Reimbursed Expenses: Specify:	$ $	$ $
(e)	Other Income:
1. Public Assistance (AFDC/GA)		$	$
2. Social Security Benefits for Party or Child/Children		$	$
3. Unemployment/Workers� Comp.		$	$
4. Interest Income per		$	$
5. Dividend Income per		$	$
6. Gross Rental Income		$	$
7. Other Income: Specify:		$ $	$ $
* Monthly Income is to be calculated using a 4.3 multiple.

(a) $                       is a reasonable amount for temporary support for           children per month.
(b) $                       is a reasonable amount for temporary maintenance per month.
(c) Payment should be made on                                                          .
$                       has been paid on the Wife's attorney fees and costs.
$                       has been paid on the Husband's attorney fees and costs.
$                       is reasonable for Wife�s/Husband's attorney fees and costs.
Additional Material Facts:

WHEREFORE, Petitioner/Respondent prays for an order granting such relief prior to trial as may be just and lawful.


	(Petitioner/Respondent)

Subscribed and sworn to before me this day of , .

My commission expires on .