Appendix A
CIRCUIT COURT OF ILLINOIS
SIXTH JUDICIAL CIRCUIT
__________________COUNTY, ILLINOIS
IN RE: THE MARRIAGE OF )
)
__________________________________ )
Plaintiff )
V. )
)
__________________________________ )
Defendant )
Case Number _______________________ )
FINANCIAL AFFIDAVIT
____ Pre-Judgment ____ Post-Judgment
_______________________, on oath state that my present
age is _______ and that:
1. (a) (PRE-JUDGMENT ONLY): The parties have been
married for ______ years, were
separated on __________________, 19____, and since
that time the obligor has paid $_____________
in child support and $____________ in maintenance
to his spouse;
(b) (POST-JUDGMENT ONLY): The marriage of
the parties was dissolved on
__________________, 19____. The obligor was ordered
to pay $__________ child
support and $____________ in maintenance to his spouse.
The said order was amended _______
times and the obligor is now paying $______________
in child support and $____________
in maintenance. The obligor (is not) (is) presently
in arrears in the sum of $_______________.
2. There are ____ children of the marriage,
aged ____________ , and presently in the custody
of ___________________________.
3. 1 have additional persons dependent on me for
support as follows:
Name: ___________________ Relationship: ___________________
___________________ ___________________
___________________ ___________________
4. My MONTHLY living expenses are as follows:Rent
or House Payment $______ Medical/Hospital Insurance
$______
Electricity $______ Life Insurance $______
Property Taxes $______ Real Estate Insurance $______
Heating $______ Personal Items $______
Water $______ Doctors $______
Telephone $______ Dentists $______
Trash Collection Charge $______ Hospital $______
Sewer Charges $______ School Expenses (Meals, Supplies)
$______
Groceries/Household Supplies $______ Cleaning & Laundry
$______
Restaurant Meals $______ Entertainment $______
Charitable Contributions $______ Gifts, Toys, Books
for Children $______
Haircuts/Beauty Shop $______ BabySitting $______
Home Repair/Maintenance $______ Other $______
Car Insurance $______ Other $______
Gas, Oil & Repairs $______
5. Debts: (payments to creditors other than
noted at #4 above)
To Whom Owed:
Purpose: Payment
per MONTH Balance
Owed
(a)__________________ Car Payment $_________ $_________
(b)__________________ Furniture/Appliances $_________
$_________
(c)__________________ Credit Card (________) $_________
$_________
(d)__________________ Credit Card (________) $_________
$_________
(e)__________________ ___________________ $_________
$_________
(f)__________________ ___________________ $_________
$_________
(g)__________________ ___________________ $_________
$_________
(h)__________________ ___________________ $_________
$_________
(i) __________________ ___________________ $_________
$_________
(j) __________________ ___________________ $_________
$_________
(k)__________________ ___________________ $_________
$_________
EMPLOYMENT INCOME
6. Present Employment:___________________ Address:_____________________________
Number of Dependents Claimed _______ Payroll Deductions:
Pay Period ( ) weekly ( ) bi-weekly (a) Taxes $______
( )semi-monthly ( ) monthly (b) Social Security $______
Hours of Employment $______ (c) Medical Insurance
(for children) $______
Hourly Wage $______ (d) Union Dues $______
Gross Income $______ (e) Retirement/Disability Contributions
$______
Total Deductions $______ (f) Other: _____________________
$______
Take-Home Pay $______ Total Deductions _______________
$______
7. Assets: (List all cash, certificates of deposit,
savings, checking and Credit Union accounts, bonds,
stocks,
household goods and appliances, motor vehicles, real
estate and all other property, real or personal,
owned by you.)
Description:
Location: Fair Cash
Market
Value Name of Co-Owners,
Joint Tenants or
Partners, if any:
(a) _________________ __________________ $___________
_________________
(b) _________________ __________________ $___________
_________________
(c) _________________ __________________ $___________
_________________
(d) _________________ __________________ $___________
_________________
(e) _________________ __________________ $___________
_________________
(f) _________________ __________________ $___________
_________________
(g) _________________ __________________ $___________
_________________
(h) _________________ __________________ $___________
_________________
RETIREMENT FUND
Type
Company Contributory
Non-Contributory Present
Value
(a) _________________ _____________________ _______________
$_________
(b) _________________ _____________________ _______________
$_________
LIFE INSURANCE
Type:
Company: Amount of
Coverage:
Beneficiary: Present
Value:
(a) ________________ ____________ $_________ _______________
$_________
(b) ________________ ____________ $_________ _______________
$_________
8. Other Income: Source Amount
______________________ $ __________
______________________ $ __________
_________________________________
Signature
Subscribed and sworn to before me this _______ day
of ____________________, 19____.
________________________________________
Notary Public Clerk
This form prepared by ______________________,
Attorney for ______________________________