COURT OF COMMON PLEAS

DIVISION OF DOMESTIC RELATIONS

HAMILTON COUNTY, OHIO

Plaintiff / Petitioner
-vs/and-
Defendant / Petitioner
Enter:
Date:
Case No.
File No.
CSEA No.
Judge
FINANCIAL DISCLOSURE AFFIDAVIT

Now comes (Obligor) and, after being duly cautioned and sworn, says:

1.	[] I am employed. My employer payroll address is .

City State Zip

I receive paychecks per year.

[] I am not employed.

2.	I receiving Worker's Compensation under Claim No. .

I receiving Unemployment Compensation under Claim No. .

3.	I have funds on deposit in financial institutions. (List all funds in all accounts in any bank, savings &	loan, credit union, regulated investment company, mutual fund or other financial institutions. Account may include one or	more of the following: checking, certificate of deposit (CD), investment, savings, individual retirement (IRA), stock	options, etc. USE ADDITIONAL PAGES IF NEEDED.)

Name of Financial Inst.	Address of Financial Inst.	Account No.	Name(s) on Account of this Affidavit	Balance as of Date

4.	I have the following additional sources of income. (List source, address and amount including, but not limited to pension (public and private) annuities, allowance, sick pay, disability pay or other benefit, commissions, trusts, bonuses, profit sharing payments or distributions, lottery winnings, lump sum payments, and private Worker's Compensation payments).

5.	I have other assets from which child support/spousal support can be paid or secured. (If affirmative, list all such assets on separate sheet of paper).

______________________________________________

Affiant-Obligor

Sworn to and subscribed in my presence this________day of____________________________, 20______________.

________________________________________	__________________________________________________

Attorney for [ ]Obligee [ ]Obligor	Notary Public

I hereby acknowledge receipt of a copy of this affidavit_____________________________________________

Obligee