Uniform Domestic Relations Form – Affidavit 1 AFFIDAVIT OF BASIC INFORMATION, INCOME, AND EXPENSES Instructions

Provide the full printed name of the affiant.

Provide the signature of the affiant.

Enter the full printed name of the person signing this affidavit (the affiant) exactly as they wish it to appear on the form.

Enter the plaintiff/petitioner's base yearly income for the year three years ago (base salary amount before overtime, commissions, or bonuses).

Enter the four-digit year that corresponds to the plaintiff/petitioner's base income reported for three years ago (for example, 2022).

Enter the defendant/petitioner's base yearly income for the year three years ago (base salary amount before overtime, commissions, or bonuses).

Enter the plaintiff/petitioner 1's base yearly income amount for the year two years ago.

Enter the four-digit calendar year corresponding to the '2 years ago' income amount (e.g., 2022).

Enter the defendant/petitioner 2's base yearly income amount for the year two years ago.

Enter the plaintiff/petitioner 1’s base yearly income amount for the third year (last year).

Enter the calendar year that corresponds to the third year (last year), e.g., 2022.

Enter the defendant/petitioner 2’s base yearly income amount for the third year (last year).

Enter the court-assigned case number or docket number for this matter exactly as it appears on court documents.

Enter the full name of the judge assigned to this case.

Enter the full name of the magistrate (if any) who is assigned to or overseeing this case.

Enter the number of other minor biological or adopted children the Plaintiff/Petitioner 1 has.

Enter the number of other minor biological or adopted children the Defendant/Petitioner 2 has.

Enter the total number of adults in your household.

Enter the amount of child support received by Plaintiff/Petitioner 1.

Enter the amount of child support received by Defendant/Petitioner 2.

Enter the average annual amount of overtime, commissions, and/or bonuses received by the Plaintiff/Petitioner 1 over the last three years (from Part A).

Enter the average annual amount of overtime, commissions, and/or bonuses received by the Defendant/Petitioner 2 over the last three years (from Part A).

Enter the plaintiff/petitioner 1's base yearly income (gross annual salary) used in the computation of current income from Part A.

Enter the defendant/petitioner 2's base yearly income (gross annual salary) used in the computation of current income from Part A.

Enter the name of the court division (for example, Domestic Relations, Probate, or General Division) that has jurisdiction over this case.

Enter the full name of the Ohio county where the court is located (for example, Franklin County).

Check this box if the defendant's highest completed education level is grade school.

Check this box if the defendant's highest completed education level is high school (diploma or equivalent).

Check this box if the defendant's highest completed education level is an associate degree.

Check this box if the defendant's highest completed education level is a bachelor’s degree.

Check this box if the defendant's highest completed education level is a postgraduate degree (education beyond a bachelor’s).

Enter any technical certifications, licenses, or professional credentials the defendant holds (e.g., IT certifications, trade licenses), or leave blank if none.

Check this box if the defendant is currently an active member of the U.S. military.

Check this box if the defendant is not currently an active member of the U.S. military.

Check this box if the defendant/petitioner 2 is currently employed.

Check this box if the defendant/petitioner 2 is not currently employed.

Enter the defendant's employment start date. Fill only if 'Defendant/Petitioner 2 - Employed: Yes' is 'Yes'.

Enter the full name of the defendant's employer (current employer or employer at time of filing). Fill only if 'Defendant/Petitioner 2 - Employed: Yes' is 'Yes'.

Enter the employer's payroll or mailing street address where paychecks or payroll correspondence is sent. Fill only if 'Defendant/Petitioner 2 - Employed: Yes' is 'Yes'.

Enter the city, state, and ZIP code for the employer's payroll address. Fill only if 'Defendant/Petitioner 2 - Employed: Yes' is 'Yes'.

Check this box if the defendant/petitioner 2 receives 12 paychecks per year. Fill only if 'Defendant/Petitioner 2 - Employed: Yes' is 'Yes'.

Check this box if the defendant/petitioner 2 receives 24 paychecks per year. Fill only if 'Defendant/Petitioner 2 - Employed: Yes' is 'Yes'.

Check this box if the defendant/petitioner 2 receives 26 paychecks per year. Fill only if 'Defendant/Petitioner 2 - Employed: Yes' is 'Yes'.

Check this box if the defendant/petitioner 2 receives 52 paychecks per year. Fill only if 'Defendant/Petitioner 2 - Employed: Yes' is 'Yes'.

Enter the name of the entity or individual to whom the eighth monthly installment payment is made.

Describe the purpose of the eighth monthly installment payment, such as car payment, credit card, or rent-to-own.

Enter the remaining balance owed for the eighth monthly installment payment.

Enter the amount of the eighth monthly installment payment.

Enter the name of the entity or person to whom the eleventh monthly installment payment is made.

Enter the reason or purpose for the eleventh monthly installment payment.

Enter the outstanding balance for the eleventh monthly installment payment.

Enter the amount of the eleventh monthly installment payment.

Enter the name of the entity to whom the fifth monthly installment payment is made.

Describe the purpose or nature of the fifth monthly installment payment.

Enter the total remaining balance due for the fifth monthly installment.

Enter the amount of the fifth monthly installment payment.

Enter the full name of the first minor or dependent child.

Enter the date of birth for the first minor or dependent child.

Enter with whom the first minor or dependent child currently lives.

Enter the name of the entity to whom the first monthly installment payment is made.

Enter the purpose of the first monthly installment payment.

Enter the remaining balance due for the first monthly installment.

Enter the monthly payment amount for the first monthly installment.

Provide the name or description for the first other expense.

Enter the amount for the first other expense.

Enter a description for the first other housing expense.

Enter the monetary amount for the first other housing expense.

Provide the monthly expense for groceries, including food, paper, cleaning products, toiletries, and other related items.

Provide the monthly expense for dining at restaurants.

Enter the full name of the fourth minor or dependent child.

Provide the date of birth for the fourth minor or dependent child.

State who the fourth minor or dependent child is currently living with.

Enter the name of the entity or individual to whom the fourth monthly installment payment is made.

Describe the purpose of the fourth monthly installment payment.

Enter the total remaining balance due for the fourth monthly installment payment.

Enter the amount of the fourth monthly installment payment.

Enter the grand total of all monthly expenses, which is the sum of sections A through H.

Enter the monthly amount for cleaning expenses.

Enter the monthly amount for lawn service and/or snow removal expenses.

Provide the source of the interest and dividend income.

Enter the amount of interest and dividend income for Plaintiff/Petitioner 1.

Enter the amount of interest and dividend income for Defendant/Petitioner 2.

Enter the state where the oath or affirmation is being made.

Enter the county where the oath or affirmation is being made.

Enter the date on which you and your spouse were legally married.

Enter the date when you and your spouse began living separately or otherwise separated.

Enter the amount for child support paid for children not born of this marriage or relationship and not adopted by these parties.

Enter the amount for expenses paid for adult children or other dependents.

Enter the amount for spousal support paid to a former spouse or spouses.

Enter the amount spent on subscriptions and books.

Enter the amount of charitable contributions made.

Enter the amount spent on memberships for associations and clubs.

Enter the amount spent on travel and vacations.

Enter the amount spent on pets.

Enter the amount spent on gifts.

Enter the amount for attorney fees.

Provide the monthly expense for physicians not covered by insurance.

Provide the monthly expense for dentists and orthodontists not covered by insurance.

Provide the monthly expense for optometrists and opticians not covered by insurance.

Provide the monthly expense for prescriptions not covered by insurance.

Describe any other monthly health care expenses not covered by insurance.

Provide the monthly amount for other health care expenses not covered by insurance.

Provide the total monthly health care expenses not covered by insurance.

Enter the monthly premium amount for life insurance.

Enter the monthly premium amount for auto insurance.

Enter the monthly premium amount for health insurance.

Enter the monthly premium amount for disability insurance.

Specify the type of other monthly insurance premium being reported.

Enter the monthly premium amount for the specified other insurance.

Enter the total monthly amount for all insurance premiums listed.

Enter the monthly expense for work and/or education-related child care for the minor child(ren).

Enter the monthly expense for other child care for the minor child(ren).

Enter the monthly expense for extraordinary parenting time travel cost for the minor child(ren).

Enter the monthly expense for school tuition for the minor child(ren).

Enter the monthly expense for school lunches for the minor child(ren).

Enter the monthly expense for school supplies for the minor child(ren).

Enter the monthly expense for extracurricular activities and lessons for the minor child(ren).

Enter the monthly expense for clothing for the minor child(ren).

Enter the monthly amount for child(ren)'s allowances.

Enter the monthly expense for special and extraordinary needs of the minor child(ren) not included elsewhere.

Specify any other monthly minor child-related expense not listed.

Enter the monthly amount for the specified other minor child-related expense.

Enter the total sum of all monthly minor child-related expenses.

Enter the monthly expense for parking and public transportation.

Enter the monthly expense for clothes, excluding those for children.

Enter the monthly expense for dry cleaning and laundry services.

Enter the monthly expense for hair and nail care services.

Describe any other personal grooming expenses not listed above.

Enter the monthly amount for other personal grooming expenses.

Describe any other monthly personal expenses not categorized.

Enter the monthly amount for other personal expenses.

Enter the total monthly personal expenses.

Enter the total monthly mandatory work expenses, including items like union dues or uniforms.

Enter the total monthly additional income taxes paid that were not deducted directly from wages.

Enter the total monthly tuition costs for education.

Enter the total monthly expenses for books, fees, and other education-related costs.

Enter the total monthly payment for your college loan.

Provide a description for the first additional monthly work or education expense not explicitly listed.

Enter the monetary amount for the first additional monthly work or education expense.

Provide a description for the second additional monthly work or education expense not explicitly listed.

Enter the monetary amount for the second additional monthly work or education expense.

Enter the total sum of all monthly work and education expenses listed above.

Enter the name of the entity or person to whom the ninth monthly installment payment is made.

Provide the purpose of the ninth monthly installment payment.

Enter the remaining balance owed for the ninth monthly installment.

Enter the amount of the ninth monthly installment payment.

Enter the full name of the Notary Public before whom the oath or affirmation was made.

Enter the day of the month on which the oath or affirmation was made.

Enter the month in which the oath or affirmation was made.

Enter the year in which the oath or affirmation was made.

Please provide the signature of the Notary Public.

Please provide the printed name of the Notary Public.

Please provide the expiration date of the Notary Public's commission.

Provide a description of the other disability benefit.

Enter the monetary amount of the other disability benefit for Plaintiff/Petitioner 1.

Enter the monetary amount of the other disability benefit for Defendant/Petitioner 2.

Please enter the type and source of other income.

Please enter the total amount of other income for Plaintiff/Petitioner 1.

Please enter the total amount of other income for Defendant/Petitioner 2.

Specify the type of other retirement benefit.

Enter the amount of other retirement benefits for Plaintiff/Petitioner 1.

Enter the amount of other retirement benefits for Defendant/Petitioner 2.

Enter the full legal name of the first party on the case (the plaintiff or petitioner) as it should appear on court documents.

Enter the full legal name of the second party on the case (the defendant or second petitioner) as it should appear on court documents.

Check this box if the highest level of education you achieved is grade school.

Check this box if the highest level of education you achieved is high school.

Check this box if the highest level of education you achieved is an associate degree.

Check this box if the highest level of education you achieved is a bachelor's degree.

Check this box if the highest level of education you achieved is post-graduate (graduate) study.

Enter any technical certifications, licenses, or specialized vocational credentials the plaintiff holds (list multiple certifications separated by commas).

Check this box if you are currently an active member of the U.S. military.

Check this box if you are not currently an active member of the U.S. military.

Check this box if Plaintiff/Petitioner 1 is currently employed.

Enter the date the plaintiff began or was hired for the current position. Fill only if 'Employed — Yes (Plaintiff/Petitioner 1)' is 'Yes'.

Enter the full legal name of the plaintiff's employer or company where the plaintiff works. Fill only if 'Employed — Yes (Plaintiff/Petitioner 1)' is 'Yes'.

Enter the employer's payroll street address used for paychecks or payroll correspondence. Fill only if 'Employed — Yes (Plaintiff/Petitioner 1)' is 'Yes'.

Enter the city, state, and ZIP code for the employer's payroll address. Fill only if 'Employed — Yes (Plaintiff/Petitioner 1)' is 'Yes'.

Check this box if Plaintiff/Petitioner 1 is paid 12 times per year (monthly). Fill only if 'Employed — Yes (Plaintiff/Petitioner 1)' is 'Yes'.

Check this box if Plaintiff/Petitioner 1 is not currently employed.

Check this box if Plaintiff/Petitioner 1 is paid 24 times per year (semi‑monthly). Fill only if 'Employed — Yes (Plaintiff/Petitioner 1)' is 'Yes'.

Check this box if Plaintiff/Petitioner 1 is paid 26 times per year (biweekly). Fill only if 'Employed — Yes (Plaintiff/Petitioner 1)' is 'Yes'.

Check this box if Plaintiff/Petitioner 1 is paid 52 times per year (weekly). Fill only if 'Employed — Yes (Plaintiff/Petitioner 1)' is 'Yes'.

Provide the monthly amount for rent or first mortgage, including taxes and insurance.

Provide the monthly amount for a second mortgage or equity line of credit.

Provide the monthly amount for real estate taxes, if not already included in the first mortgage.

Provide the monthly amount for renter's or homeowner's insurance, if not already included in the first mortgage.

Provide the monthly amount for homeowner or condominium association fees.

Enter the full name of the second minor or dependent child.

Enter the date of birth for the second minor or dependent child.

Enter the name of the person or people the second minor or dependent child lives with.

Enter the name of the entity or person to whom the second monthly installment payment is made.

Describe the purpose of the second monthly installment payment.

Enter the remaining balance due for this second monthly installment payment.

Enter the monthly payment amount for this second monthly installment.

Provide a description for the second other expense.

Enter the monthly amount for the second other expense.

Provide a description for the second other housing expense.

Enter the monthly amount for the second other housing expense.

Enter the name of the entity or individual to whom the seventh monthly installment payment is made.

Provide a brief description of the purpose for the seventh monthly installment payment.

Enter the current outstanding balance for the seventh monthly installment payment.

Enter the amount of the seventh monthly payment.

Enter the name of the entity or individual to whom the sixth monthly installment payment is made.

Provide a brief description of the purpose for the sixth monthly installment payment.

Enter the remaining balance due for the sixth monthly installment payment.

Enter the amount of the sixth monthly installment payment.

Enter the amount of Social Security benefits for Plaintiff/Petitioner 1.

Enter the amount of Social Security benefits for Defendant/Petitioner 2.

Check this box if the Social Security or Veteran's benefits received for the child(ren) are due to the child's disability.

Enter the total amount of Social Security or Veteran's benefits received for child(ren) by Plaintiff/Petitioner 1.

Enter the total amount of Social Security or Veteran's benefits received for child(ren) by Defendant/Petitioner 2.

Enter the amount of Social Security retirement benefits for Plaintiff/Petitioner 1.

Enter the amount of Social Security retirement benefits for Defendant/Petitioner 2.

Enter the amount of spousal support received by Plaintiff/Petitioner 1.

Enter the amount of spousal support received by Defendant/Petitioner 2.

Enter the amount of Supplemental Security Income (SSI) and/or public assistance received by Plaintiff/Petitioner 1.

Enter the amount of Supplemental Security Income (SSI) and/or public assistance received by Defendant/Petitioner 2.

Enter the plaintiff/petitioner 1's date of birth.

Enter the defendant/petitioner 2's date of birth.

Enter the last four digits of the Plaintiff/Petitioner 1's Social Security number.

Enter the last four digits of the Defendant/Petitioner 2's Social Security number.

Enter the primary phone number for Plaintiff/Petitioner 1, including area code and any extension if applicable.

Enter the primary phone number for Defendant/Petitioner 2, including area code and any extension if applicable.

Enter the Plaintiff/Petitioner 1's email address for contact (for example: [email protected]).

Enter the Defendant/Petitioner 2's email address for contact (for example: [email protected]).

Check this box if Plaintiff/Petitioner 1 needs an interpreter.

Check this box if Plaintiff/Petitioner 1 does not need an interpreter.

Check this box if Defendant/Petitioner 2 needs an interpreter.

Check this box if Defendant/Petitioner 2 does not need an interpreter.

If an interpreter is needed for Plaintiff/Petitioner 1, briefly describe why and what language or communication assistance is required (e.g., language spoken, sign language, limited English proficiency). Fill only if 'Row 5 - Interpreter needed (Plaintiff/Petitioner 1) - Yes' is 'Yes'.

If an interpreter is needed for Defendant/Petitioner 2, briefly describe why and what language or communication assistance is required (e.g., language spoken, sign language, limited English proficiency). Fill only if 'Row 5 - Interpreter needed (Defendant/Petitioner 2) - Yes' is 'Yes'.

Check this box if Plaintiff/Petitioner 1's overall health is good.

Check this box if Plaintiff/Petitioner 1's overall health is fair.

Check this box if Plaintiff/Petitioner 1's overall health is poor.

Check this box if Defendant/Petitioner 2's overall health is good.

Check this box if Defendant/Petitioner 2's overall health is fair.

Check this box if Defendant/Petitioner 2's overall health is poor.

If the plaintiff/petitioner’s health is not good, briefly describe the health problems, limitations, treatment needs, medications, or any other relevant medical details that affect daily functioning or ability to work. Fill only if 'Table Row 7 - Petitioner 1 Health: Fair', 'Table Row 7 - Petitioner 1 Health: Poor' is 'any' 27 or 28.

If the defendant/petitioner’s health is not good, briefly describe the health problems, limitations, treatment needs, medications, or any other relevant medical details that affect daily functioning or ability to work. Fill only if 'Table Row 7 - Petitioner 2 Health: Fair', 'Table Row 7 - Petitioner 2 Health: Poor' is 'any' 30 or 31.

Enter the name of the entity to whom the tenth monthly installment payment is made.

Describe the purpose of the tenth monthly installment payment.

Enter the remaining balance due for the tenth monthly installment.

Enter the monthly payment amount for the tenth installment.

Enter the full name of the third minor or dependent child.

Enter the date of birth for the third minor or dependent child.

Enter who the third minor or dependent child lives with.

Enter the name of the person or entity to whom the third monthly installment payment is made.

Describe the purpose of the third monthly installment payment.

Enter the remaining balance due for the third monthly installment.

Enter the amount of the third monthly installment payment.

Provide the total monthly housing expense.

Enter the total sum of all monthly installment payments, including bankruptcy payments, from section H.

Enter the total monthly amount for all other expenses.

Enter the total yearly income for Plaintiff/Petitioner 1.

Enter the total yearly income for Defendant/Petitioner 2.

Enter the monthly expense for vehicle loan or lease.

Enter the monthly expense for vehicle maintenance.

Enter the monthly expense for gasoline.

Enter the name of the entity or individual to whom the twelfth monthly installment payment was made.

Provide a description of the purpose for the twelfth monthly installment payment.

Enter the balance still due for the twelfth monthly installment payment.

Enter the amount of the twelfth monthly installment payment.

Enter the amount of unemployment compensation received by Plaintiff/Petitioner 1.

Enter the amount of unemployment compensation received by Defendant/Petitioner 2.

Enter the monthly expense for electric utilities.

Enter the monthly expense for gas, fuel oil, or propane utilities.

Enter the monthly expense for water and sewer utilities.

Enter the monthly expense for telephone and/or cell phone utilities.

Enter the monthly expense for trash collection utilities.

Enter the monthly expense for cable or satellite television utilities.

Enter the monthly expense for internet service utilities.

Enter the workers' compensation amount for Defendant/Petitioner 2.

Enter the total amount of overtime, commissions, and bonuses the Plaintiff/Petitioner 1 received in the year three years ago.

Enter the total amount of overtime, commissions, and bonuses the Defendant/Petitioner 2 received in the year three years ago.

Enter the total amount of yearly overtime, commissions, and/or bonuses received by the plaintiff two years ago.

Enter the total amount of yearly overtime, commissions, and/or bonuses received by the defendant two years ago.

Enter the total amount of yearly overtime, commissions, and/or bonuses received by the plaintiff/petitioner 1 for the last year.

Enter the total amount of yearly overtime, commissions, and/or bonuses received by the defendant/petitioner 2 for the last year.