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FILED
Commen Fisas Court
Jackson, OH
IN THE COURT OF COMMON PLEAS
DOMESTIC DIVISION DEC 13 2023
WALI Oe COUNTY, OHIO SETH | MICHAEL, CLERK
BLSuty
Cade Farndn Case No. 23- bw -00%W
Plaintiff/Petitioner 1
Judge. DEAN
vs./and
Magistrate WET TY
_ducns Faire
Defendant/Petitioner 2
Instructions: Check local court rules to determine when this form must be filed. This affidavit is used
to make complete disclosure of income, expenses, and money owed. It is used to determine child and
spousal support. Do not leave any category blank. For each item, if none, put “NONE.” If you do not
know exact figures for any item, give your best estimate, and put “EST.” If you need more space, add
additional pages
—_ —
AFFIDAVIT OF BASIC INFORMATION, INCOME, AND EXPENSES
Affidavit of tin Matters FARA
(Print Name)
Date of mariage] [tq ill Date of separation g/24/ 2025
SECTION | —- BASIC INFORMATION
Plaintiff/Petitioner 1 Defendant/Petitioner 2
Is an interpreter needed? [_] Yes orrf No Is an interpreter needed? {_] Yes or No
\f yes, explain: If yes, explain:
a
H Ith: Health
‘ood (] Fair (_] Poor
health is not good, please explain:
(Good
lf health is not i
[Fair
ef Poor
“Pslease explain:
heart
p jee
Surges t
§& tn
ight ed
Supreme Court of Ohio Page 1 of 8
Uniform Domestic Relations Form~ Affidavit 1 AFFIDAVIT
OF BASIC INFORMATION, INCOME, AND EXPENSES
Approved under Ohio Civil Rule 84
Amended: June 1, 2021
Education: (Check highest level achieved) Education: (Check highest level achieved)
(Grade School [j High School (Grade School ([] High School
D1 Associate Bachelor's (] Post Graduate (Associate achelor’s [_] Post Graduate
Other Technical Certifications: Other Technical Certifications
Active ‘dno, of the U.S. Military Active Member of the U.S. Military
OYes (Yes if No
SECTION Il - INCOME
PlaintiffiPetitionert
= §§ Defendant/Petitioner 2
Employed
Date of Employment
e. Yes [No oe Yes BiiNo
weelS
Name of Employer tex
Payroll Address
Payroll City, State,
Scheduled Paychecks Per Year
Zip Hs
(112 (24 [yes 152
A. YEARLY INCOME, OVERTIME, COMMISSIONS, AND BONUSES FOR PAST THREE YEARS
Year Defendant/Petitioner2
Soo 3 years ago — 20020 $
Base yearlyitincome | $. 2 years ago — 207 $_Q2F00
;{ $ as5 Last year — 20a2 $_O
| $. 3 years ago — 20 $
Yearly overtime.
commissions, 2 years ago — 20 $
and/or bonuses $ Last year — 20 $
B. COMPUTATION
OF CURRENT INCOME
Plaintiff/Petitioner 1 Defendant/Petitioner 2
Base Yearly Income
Average yearly overtime.
commissions, and/or bonuses
over last 3 years (from part A)
Supreme Court of Ohio Page
2 of 8
Uniform Domestic Relations Form — Affidavit1 AFFIDAVIT OF
BASIC INFORMATION, INCOME, AND EXPENSES
Approved under Ohio Civil Rule 84
Amended: June 1, 2021
PtaintiffiPetitioner 1 Defendant/Petitioner 2
Unemployment Compensation $ 6 $ @O
Disability Benefits
Workers’ Compensation $ oO
Social Security 2
Other:
Retirement Benefits
Social Security
Other:
Spousal Support Received
Interest and dividend income
(source)
Other income (type and source)
TOTAL YEARLY INCOME ©
Supplemental Security Income So
(SSI) and/or public assistance
Social Security or Veteran’s
benefits received for child(ren)
(Based on parent's disability
(Based on child's disability
Child support you receive from
a child support enforcement
agency or court order for minor
and/or dependent child(ren) not
of the marriage or relationship $ co
a
SECTION ill - CHILDREN AND HOUSEHOLD RESIDENTS
Minor and/or dependent child(ren) who is/are adopted or born from this marriage or relationship:
Name Date of birth Living with
plier TN Cedrod mm cart: Bor’
se Bev
Supreme Court of Ohio Page 3 of 8
Uniform Domestic Relations Form — Affidavit 1 AFFIDAVIT
OF BASIC INFORMATION, INCOME, AND EXPENSES
Approved under Ohio Civil Rule 84
Amended: June 1, 2021
In addition to the above child(ren):
Plaintiff/Petitioner 1 has, other minor biological! or adopted child(ren).
Defendant/Petitioner 2 has, other minor biological or adopted child(ren)
There is/are. f adult(s) in your household.
SECTION IV - EXPENSES
List monthly expenses below for your present household.
A. MONTHLY HOUSING EXPENSES
Rent or first mortgage (including taxes and insurance)
Second mortgage/equity line of credit
Real estate taxes (if not included above)
Renter or homeowner's insurance (if net included above)
Homeowner or condominium association fee
Utilities
° Electric : fo
° Gas, fuel oil, propane
ts
° Water and sewer
° Telephone and/or cell phone
° Trash collection
° Cable/satellite television
$_
OO
* Internet service s_ 50
Cleaning
Lawn service and/or snow removal
Other:
TOTAL MONTHLY: = ao
B. OTHER MONTHLY LIVING EXPENSES
Food
° Groceries (including food, paper, cleaning products, toiletries, and other)
Zoo
° Restaurant
Transportation
° Vehicle loan, lease
° Vehicle maintenance
° Gasoline FOB
Supreme Court of Ohio Page 4 of 8
Uniform Domestic Relations Form ~ Affidavit 1 AFFIDAVIT
OF BASIC INFORMATION, INCOME, AND EXPENSES
Approved under Ohio Civil Rule 84
Amended: June 1, 2021
° Parking, public transportation
Clothing
° Clothes (other than child(ren)’s) s__ fO.
° Dry cleaning and laundry
Personal grooming
° Hair and nail care
° Other:
568
Other:
TOTAL MONTHLY:
Cc. |
(for child(ren) of the marriage or relationship)
Work and/or education-related child care
Other child care
Extraordinary parenting time travel cost
School tuition
School lunches
School supplies $ ¥O
Extracurricular activities and lessons
Clothing
Child(ren)'s allowances s_
gO
Special and extraordinary needs of child(ren) (not included elsewhere)
Other:
TOTAL MONTHLY: s_ 4O.
D. MONTHLY INSURANCE PREMIUMS
Life 8.
=
Auto
Health
Disability
Other:
TOTAL MONTHLY: sae
Supreme Court of Ohio Page 50f8
Uniform Domestic Relations Form — Affidavit 1 AFFIDAVIT
OF BASIC INFORMATION, INCOME, AND EXPENSES
Approved under Ohio Civil Rule 84
Amended: June 1, 2021
E, MONTHLY WORK AND EDUCATION EXPENSES FOR SELF
Mandatory work expenses (union dues, uniforms, or other)
Additional income taxes paid (not deducted from wages)
Tuition
Books, fees, and other
College loan
Other:
TOTAL MONTHLY:
F
, (not covered by insurance)
Physicians
Dentists and orthodontists
Optometrists and opticians
Prescriptions
Other:
TOTAL MONTHLY: s__ OO
G. MISCELLANEOUS
MONTHLY EXPENSES
Extraordinary obligations for other minor/handicapped child(ren) [for
child(ren) who were not born of this marriage or relationship and were not
adopted by these parties]
Child support for child(ren) who were not born of this marriage
or relationship and were not adopted by these parties
Expenses paid for adult child(ren) or other dependent(s)
Spousal support paid to former spouse(s)
Subscriptions and books
Charitable contributions
Memberships (associations and clubs)
Travel and vacations
Pets
Gifts
Attorney fees s_Jopo0_
Supreme Court of Ohio Page 6 of 8
Uniform Domestic Relations Form — Affidavit 1 AFFIDAVIT
OF BASIC INFORMATION, INCOME, AND EXPENSES
Approved under Ohio Civil Rule 84
Amended: June 1, 2021
Other: $.
$
TOTAL MONTHLY: §$
H. MONTHLY INSTALLMENT PAYMENTS INCLUDING BANKRUPTCY PAYMENTS
(Do not repeat expenses already listed.)
Examples: car, credit card, rent-to-own, or cash advance payments
To whom paid Purpose Balance due Monthly, we
Ont ee Li geneton [4,991.94 $ G/
seethease IG 00d, $ (C,2>O.
L
£5 080
2900 $
$ SS
TOTAL MONTHLY:
GRAND TOTAL MONTHLY EXPENSES (Sum of A through H): $
Supreme Court of Ohio Page 7 of8
Uniform Domestic Relations Form - Affidavit 1 AFFIDAVIT
OF BASIC INFORMATION, INCOME, AND EXPENSES
Approved under Ohio Civil Rule 84
Amended: June 1, 2021
OATH OR AFFIRMATION
Do not sign until Notary Public is present)
|, (printname)_ VUstr277A Fr Lew. raf , Swear or affirm that | have read this Affidavit and, to the best
of my knowledge and belief, the oo and information stated in thi Affidavit are true, accurate, and
complete. | understand that if | do not tell the truth, | may be subj fo penalties for perjury.
Yoyf Signature
STATE OF ( Na ’a
)ss
COUNTY OF Iycls ort )
Sworn to or affirmed before me by. Uishy becr0l wis 70 day of Nowe wn beg
Signature of Notary Public
-
Cam
Printed Name of Notary Public
Commission Expiration Date: LABCTIAAG
(Affix seal here)
Supreme Court of Ohio Page
8 of 8
Uniform Domestic Relations Form — Affidavit 1 AFFIDAVIT
OF BASIC INFORMATION, INCOME, AND EXPENSES
Approved under Ohio Civil Rule 84
Amended: June1, 2021
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FILED Commen Fisas Court Jackson, OH IN THE COURT OF COMMON PLEAS DOMESTIC DIVISION DEC 13 2023 WALI Oe COUNTY, OHIO SETH | MICHAEL, CLERK BLSuty Cade Farndn Case No. 23- bw -00%W Plaintiff/Petitioner 1 Judge. DEAN vs./and Magistrate WET TY _ducns Faire Defendant/Petitioner 2 Instructions: Check local court rules to determine when this form must be filed. This affidavit is used to make complete disclosure of income, expenses, and money owed. It is used to determine child and spousal support. Do not leave any category blank. For each item, if none, put “NONE.” If you do not know exact figures for any item, give your best estimate, and put “EST.” If you need more space, add additional pages —_ — AFFIDAVIT OF BASIC INFORMATION, INCOME, AND EXPENSES Affidavit of tin Matters FARA (Print Name) Date of mariage] [tq ill Date of separation g/24/ 2025 SECTION | —- BASIC INFORMATION Plaintiff/Petitioner 1 Defendant/Petitioner 2 Is an interpreter needed? [_] Yes orrf No Is an interpreter needed? {_] Yes or No \f yes, explain: If yes, explain: a H Ith: Health ‘ood (] Fair (_] Poor health is not good, please explain: (Good lf health is not i [Fair ef Poor “Pslease explain: heart p jee Surges t §& tn ight ed Supreme Court of Ohio Page 1 of 8 Uniform Domestic Relations Form~ Affidavit 1 AFFIDAVIT OF BASIC INFORMATION, INCOME, AND EXPENSES Approved under Ohio Civil Rule 84 Amended: June 1, 2021 Education: (Check highest level achieved) Education: (Check highest level achieved) (Grade School [j High School (Grade School ([] High School D1 Associate Bachelor's (] Post Graduate (Associate achelor’s [_] Post Graduate Other Technical Certifications: Other Technical Certifications Active ‘dno, of the U.S. Military Active Member of the U.S. Military OYes (Yes if No SECTION Il - INCOME PlaintiffiPetitionert = §§ Defendant/Petitioner 2 Employed Date of Employment e. Yes [No oe Yes BiiNo weelS Name of Employer tex Payroll Address Payroll City, State, Scheduled Paychecks Per Year Zip Hs (112 (24 [yes 152 A. YEARLY INCOME, OVERTIME, COMMISSIONS, AND BONUSES FOR PAST THREE YEARS Year Defendant/Petitioner2 Soo 3 years ago — 20020 $ Base yearlyitincome | $. 2 years ago — 207 $_Q2F00 ;{ $ as5 Last year — 20a2 $_O | $. 3 years ago — 20 $ Yearly overtime. commissions, 2 years ago — 20 $ and/or bonuses $ Last year — 20 $ B. COMPUTATION OF CURRENT INCOME Plaintiff/Petitioner 1 Defendant/Petitioner 2 Base Yearly Income Average yearly overtime. commissions, and/or bonuses over last 3 years (from part A) Supreme Court of Ohio Page 2 of 8 Uniform Domestic Relations Form — Affidavit1 AFFIDAVIT OF BASIC INFORMATION, INCOME, AND EXPENSES Approved under Ohio Civil Rule 84 Amended: June 1, 2021 PtaintiffiPetitioner 1 Defendant/Petitioner 2 Unemployment Compensation $ 6 $ @O Disability Benefits Workers’ Compensation $ oO Social Security 2 Other: Retirement Benefits Social Security Other: Spousal Support Received Interest and dividend income (source) Other income (type and source) TOTAL YEARLY INCOME © Supplemental Security Income So (SSI) and/or public assistance Social Security or Veteran’s benefits received for child(ren) (Based on parent's disability (Based on child's disability Child support you receive from a child support enforcement agency or court order for minor and/or dependent child(ren) not of the marriage or relationship $ co a SECTION ill - CHILDREN AND HOUSEHOLD RESIDENTS Minor and/or dependent child(ren) who is/are adopted or born from this marriage or relationship: Name Date of birth Living with plier TN Cedrod mm cart: Bor’ se Bev Supreme Court of Ohio Page 3 of 8 Uniform Domestic Relations Form — Affidavit 1 AFFIDAVIT OF BASIC INFORMATION, INCOME, AND EXPENSES Approved under Ohio Civil Rule 84 Amended: June 1, 2021 In addition to the above child(ren): Plaintiff/Petitioner 1 has, other minor biological! or adopted child(ren). Defendant/Petitioner 2 has, other minor biological or adopted child(ren) There is/are. f adult(s) in your household. SECTION IV - EXPENSES List monthly expenses below for your present household. A. MONTHLY HOUSING EXPENSES Rent or first mortgage (including taxes and insurance) Second mortgage/equity line of credit Real estate taxes (if not included above) Renter or homeowner's insurance (if net included above) Homeowner or condominium association fee Utilities ° Electric : fo ° Gas, fuel oil, propane ts ° Water and sewer ° Telephone and/or cell phone ° Trash collection ° Cable/satellite television $_ OO * Internet service s_ 50 Cleaning Lawn service and/or snow removal Other: TOTAL MONTHLY: = ao B. OTHER MONTHLY LIVING EXPENSES Food ° Groceries (including food, paper, cleaning products, toiletries, and other) Zoo ° Restaurant Transportation ° Vehicle loan, lease ° Vehicle maintenance ° Gasoline FOB Supreme Court of Ohio Page 4 of 8 Uniform Domestic Relations Form ~ Affidavit 1 AFFIDAVIT OF BASIC INFORMATION, INCOME, AND EXPENSES Approved under Ohio Civil Rule 84 Amended: June 1, 2021 ° Parking, public transportation Clothing ° Clothes (other than child(ren)’s) s__ fO. ° Dry cleaning and laundry Personal grooming ° Hair and nail care ° Other: 568 Other: TOTAL MONTHLY: Cc. | (for child(ren) of the marriage or relationship) Work and/or education-related child care Other child care Extraordinary parenting time travel cost School tuition School lunches School supplies $ ¥O Extracurricular activities and lessons Clothing Child(ren)'s allowances s_ gO Special and extraordinary needs of child(ren) (not included elsewhere) Other: TOTAL MONTHLY: s_ 4O. D. MONTHLY INSURANCE PREMIUMS Life 8. = Auto Health Disability Other: TOTAL MONTHLY: sae Supreme Court of Ohio Page 50f8 Uniform Domestic Relations Form — Affidavit 1 AFFIDAVIT OF BASIC INFORMATION, INCOME, AND EXPENSES Approved under Ohio Civil Rule 84 Amended: June 1, 2021 E, MONTHLY WORK AND EDUCATION EXPENSES FOR SELF Mandatory work expenses (union dues, uniforms, or other) Additional income taxes paid (not deducted from wages) Tuition Books, fees, and other College loan Other: TOTAL MONTHLY: F , (not covered by insurance) Physicians Dentists and orthodontists Optometrists and opticians Prescriptions Other: TOTAL MONTHLY: s__ OO G. MISCELLANEOUS MONTHLY EXPENSES Extraordinary obligations for other minor/handicapped child(ren) [for child(ren) who were not born of this marriage or relationship and were not adopted by these parties] Child support for child(ren) who were not born of this marriage or relationship and were not adopted by these parties Expenses paid for adult child(ren) or other dependent(s) Spousal support paid to former spouse(s) Subscriptions and books Charitable contributions Memberships (associations and clubs) Travel and vacations Pets Gifts Attorney fees s_Jopo0_ Supreme Court of Ohio Page 6 of 8 Uniform Domestic Relations Form — Affidavit 1 AFFIDAVIT OF BASIC INFORMATION, INCOME, AND EXPENSES Approved under Ohio Civil Rule 84 Amended: June 1, 2021 Other: $. $ TOTAL MONTHLY: §$ H. MONTHLY INSTALLMENT PAYMENTS INCLUDING BANKRUPTCY PAYMENTS (Do not repeat expenses already listed.) Examples: car, credit card, rent-to-own, or cash advance payments To whom paid Purpose Balance due Monthly, we Ont ee Li geneton [4,991.94 $ G/ seethease IG 00d, $ (C,2>O. L £5 080 2900 $ $ SS TOTAL MONTHLY: GRAND TOTAL MONTHLY EXPENSES (Sum of A through H): $ Supreme Court of Ohio Page 7 of8 Uniform Domestic Relations Form - Affidavit 1 AFFIDAVIT OF BASIC INFORMATION, INCOME, AND EXPENSES Approved under Ohio Civil Rule 84 Amended: June 1, 2021 OATH OR AFFIRMATION Do not sign until Notary Public is present) |, (printname)_ VUstr277A Fr Lew. raf , Swear or affirm that | have read this Affidavit and, to the best of my knowledge and belief, the oo and information stated in thi Affidavit are true, accurate, and complete. | understand that if | do not tell the truth, | may be subj fo penalties for perjury. Yoyf Signature STATE OF ( Na ’a )ss COUNTY OF Iycls ort ) Sworn to or affirmed before me by. Uishy becr0l wis 70 day of Nowe wn beg Signature of Notary Public - Cam Printed Name of Notary Public Commission Expiration Date: LABCTIAAG (Affix seal here) Supreme Court of Ohio Page 8 of 8 Uniform Domestic Relations Form — Affidavit 1 AFFIDAVIT OF BASIC INFORMATION, INCOME, AND EXPENSES Approved under Ohio Civil Rule 84 Amended: June1, 2021