Official form section
Court case information Judicial circuit
Filing county
Case number
Division
Petitioner full legal name
Respondent full legal name
Your full legal name (person completing this affidavit)
Official form section
Employment information Age
Occupation
Mark if you are unemployed Select one Mark this checkbox
Unemployment explanation
Unemployment explanation - additional line
Mark if you are employed Select one Mark this checkbox
Employer name
Employer address
Employer city, state, and ZIP code
Employer telephone number
Pay rate
Pay frequency Select one Every week Every other week Twice a month Monthly Other
Other pay-frequency description
Expected employment-status change
Expected employment-status change - additional line 1
Expected employment-status change - additional line 2
Mark if you currently have more than one job Select one Mark this checkbox
Mark if you are retired Select one Mark this checkbox
Retirement date
Employer from whom retired
Retired employer address
Retired employer city, state, and ZIP code
Retired employer telephone number
Anticipated retirement date
Mark if you are in or planning to enter DROP or another deferred compensation or anticipated retirement plan Select one Mark this checkbox
Last year's gross-income year
Your gross income for that year
Other party's gross income for that year, if known
Official form section
Present monthly gross income Gross Salary or Wages
Bonuses, commissions, allowances, overtime, tips, and similar payments
Business Income
Disability benefits/SSI for you
Workers Compensation
Reemployment Assistance
Pension, Retirement, or Annuity Payments
Social Security Benefits
Alimony received from this case
Alimony received from other cases
Interest and Dividends
Rental Income
Income from royalties, trusts, or estates
Reimbursed expenses and in-kind payments to the extent that they reduce personal living expenses
Gains derived from dealing in property
Other recurring income - identify the source
Other recurring income - official line 15
Other recurring income - official line 16
Official form section
Present monthly deductions Federal, State and Local income tax
Income-tax filing status
Number of dependents claimed
FICA or self-employment taxes
Medicare payments
Mandatory union dues
Mandatory retirement payments
Health insurance payments for you only
Court-ordered child support actually paid for children from another relationship
Alimony actually paid in this case
Alimony actually paid in other cases
Official form section
Average monthly expenses Mortgage or rent payments
Property taxes (if not included on mortgage)
Insurance on residence (if not included on mortgage)
Condominium maintenance fees and homeowners association fees
Electricity
Water, garbage, and sewer
Telephone
Fuel oil or natural gas
Repairs and maintenance
Lawn Care
Pool maintenance
Pest control
Misc household
Food and home supplies
Meals outside home
Cable tv / internet
Subscription streaming services
Alarm service contract
Service contracts on appliances
Housekeeping service
Communication technology / remote working subscriptions
Other household expense - official line 22
Other household expense - official line 23
Other household expense - official line 24
Other household expense - official line 25
Other household expense - official line 26
Number of automobiles for which you incur expenses
Gasoline and oil
Electric car charging (outside of the home)
Repairs
Auto tags
Insurance
Payments (lease or financing)
Rental
Alternative transportation (bus, rail, carpool, taxi, ridesharing, etc)
Tolls and parking
Automobile subscriptions and roadside services
Other automobile expense - monthly amount
Other automobile expense - description
Number of minor or dependent children common to both parties
Childcare
School tuition
School supplies, books, and fees
Extracurricular activities
School uniforms
Lunch money
Private lessons or tutoring
Allowances
Clothing
Entertainment (movies, parties, video games)
Health insurance (including dental and vision)
Medical, dental, prescriptions (nonreimbursed only)
Psychiatric / psychological / counselor
Orthodontic
Grooming
Nonprescription medication, supplements, and vitamins
Cosmetics, toiletries, and sundries
Gifts from child(ren) to others (other children, relatives, teachers)
Camp or summer activities
Clubs
Cost required to exercise time-sharing (supervised visitation, travel and lodging expenses, etc)
Religious training
Remote learning
Subscription service (if not listed on line 17 above)
Other expense for children common to both parties - official line 64
Number of children from another relationship
Other expense for children from another relationship - official line 66
Other expense for children from another relationship - official line 67
Other expense for children from another relationship - official line 68
Other expense for children from another relationship - official line 69
Health insurance
Life insurance
Dental insurance
Vision insurance
Long term care insurance
Disability insurance
Other insurance expense - official line 77
Other insurance expense - official line 78
Dry cleaning and laundry
Clothing
Medical, dental, and prescription (unreimbursed only)
Psychiatric, psychological, or counselor (unreimbursed only)
Non-prescription medications, cosmetics, toiletries, and sundries
Grooming
Gifts
Pet care
Club dues and membership
Sports and hobbies
Entertainment
Periodicals / books / other subscription service
Charitable donations
Gambling and lottery
Tobacco, alcohol, and vaping
Attorney fees and court costs - total monthly amount
Attorney fees and court costs related to this case
Other attorney fees and court costs
Professional training fees (unreimbursed only)
Vacations
Religious organizations
Bank charges / credit card fees
Education expenses (unreimbursed only)
Other regular recurring expense - monthly amount
Other regular recurring expense - description
Other monthly expense - official line 102
Other monthly expense - official line 103
Other monthly expense - official line 104
Monthly payment and creditor - official line 106
Monthly payment and creditor - official line 107
Monthly payment and creditor - official line 108
Monthly payment and creditor - official line 109
Monthly payment and creditor - official line 110
Monthly payment and creditor - official line 111
Monthly payment and creditor - official line 112
Monthly payment and creditor - official line 113
Monthly payment and creditor - official line 114
Monthly payment and creditor - official line 115
Monthly payment and creditor - official line 116
Monthly payment and creditor - official line 117
Monthly payment and creditor - official line 118
Official form section Assets Enter only what you want transferred to each official asset-table line. Leave any unused line blank.
Official line 1 Cash on hand
Official line 2 Bank and credit-union accounts
Official line 3 Bank and credit-union accounts — additional line
Official line 4 Bank and credit-union accounts — additional line
Official line 5 Digital wallets
Official line 6 Digital wallets — additional line
Official line 7 Digital wallets — additional line
Official line 8 Virtual currency or cryptocurrency
Official line 9 Virtual currency or cryptocurrency — additional line
Official line 10 Virtual currency or cryptocurrency — additional line
Official line 11 Non-fungible tokens
Official line 12 Non-fungible tokens — additional line
Official line 13 Stocks and bonds
Official line 14 Stocks and bonds — additional line
Official line 15 Stocks and bonds — additional line
Official line 16 Notes owed to you
Official line 17 Notes owed to you — additional line
Official line 18 Notes owed to you — additional line
Official line 19 Money owed without a note
Official line 20 Money owed without a note — additional line
Official line 21 Money owed without a note — additional line
Official line 22 Home real estate
Official line 23 Other real estate
Official line 24 Other real estate — additional line
Official line 25 Other real estate — additional line
Official line 26 Other real estate — additional line
Official line 27 Other real estate — additional line
Official line 28 Other real estate — additional line
Official line 29 Business interests
Official line 30 Business interests — additional line
Official line 31 Business interests — additional line
Official line 32 Business interests — additional line
Official line 33 Business interests — additional line
Official line 34 Automobiles
Official line 35 Automobiles — additional line
Official line 36 Automobiles — additional line
Official line 37 Automobiles — additional line
Official line 39 Boats — additional line
Official line 40 Boats — additional line
Official line 41 Other vehicles
Official line 42 Other vehicles — additional line
Official line 43 Other vehicles — additional line
Official line 44 Retirement plans
Official line 45 Retirement plans — additional line
Official line 46 Retirement plans — additional line
Official line 47 Retirement plans — additional line
Official line 48 Furniture and furnishings in the home
Official line 49 Furniture and furnishings in the home — additional line
Official line 50 Furniture elsewhere
Official line 51 Furniture elsewhere — additional line
Official line 52 Collectibles and commodities
Official line 53 Collectibles and commodities — additional line
Official line 54 Collectibles and commodities — additional line
Official line 56 Jewelry — additional line
Official line 57 Life insurance
Official line 58 Sporting, hobby, and entertainment items
Official line 60 Firearms and ammunition
Official line 61 Firearms and ammunition — additional line
Official line 62 Firearms and ammunition — additional line
Official line 63 Judgments owed to you
Official line 64 Judgments owed to you — additional line
Official line 65 Judgments owed to you — additional line
Official line 66 Patents, trademarks, and copyrights
Official line 67 Patents, trademarks, and copyrights — additional line
Official line 68 Patents, trademarks, and copyrights — additional line
Official line 69 Patents, trademarks, and copyrights — additional line
Official line 70 Other assets
Official line 71 Other assets — additional line
Official line 72 Other assets — additional line
Official line 73 Other assets — additional line
Official line 74 Other assets — additional line
Official line 75 Other assets — additional line
Official line 76 Other assets — additional line
Official line 77 Other assets — additional line
Official form section Liabilities Enter only what you want transferred to each official liability-table line. Leave any unused line blank.
Official line 80 Mortgages
Official line 90 Mortgages — additional line
Official line 91 Mortgages — additional line
Official line 92 Mortgages — additional line
Official line 93 Charge and credit-card accounts
Official line 94 Charge and credit-card accounts — additional line
Official line 95 Charge and credit-card accounts — additional line
Official line 96 Charge and credit-card accounts — additional line
Official line 97 Charge and credit-card accounts — additional line
Official line 98 Student loans
Official line 99 Student loans — additional line
Official line 100 Student loans — additional line
Official line 101 Student loans — additional line
Official line 102 Medical liabilities
Official line 103 Medical liabilities — additional line
Official line 104 Medical liabilities — additional line
Official line 105 Auto loans
Official line 106 Auto loans — additional line
Official line 107 Auto loans — additional line
Official line 108 Bank and credit-union loans
Official line 109 Bank and credit-union loans — additional line
Official line 110 Tax liabilities
Official line 111 Tax liabilities — additional line
Official line 113 Notes — additional line
Official line 114 Money owed without a note
Official line 115 Money owed without a note — additional line
Official line 116 Judgments
Official line 117 Judgments — additional line
Official line 118 Judgments — additional line
Official line 119 Other liabilities
Official line 120 Other liabilities — additional line
Official line 121 Other liabilities — additional line
Official line 122 Other liabilities — additional line
Official line 123 Other liabilities — additional line
Official line 124 Other liabilities — additional line
Official line 125 Other liabilities — additional line
Official form section Contingent assets and liabilities These are the official contingent asset and contingent liability lines. Leave any unused line blank.
Official line 52 (additional) Official contingent-table line
Official line 128 Contingent assets — stock options
Official line 129 Contingent assets — other
Official line 130 Contingent assets — additional line
Official line 131 Contingent assets — additional line
Official line 134 Contingent liabilities
Official line 135 Contingent liabilities — additional line
Official line 136 Contingent liabilities — attorney fees
Official line 137 Contingent liabilities — additional line
Official form section
Child support guidelines worksheet Child Support Guidelines Worksheet status Select one IS or WILL BE filed IS NOT being filed
Official form section
Your contact information for the signature page Address
City, state, and ZIP code
Email address
Printed name
