we APR-O2-01 MON 09:24 HOFFMANLAWOFF ICES FAX NO. 7852332173 P02
DONALD R. HOFFMAN (#07332)
HOFFMAN & HOFFMAN
112 West 7th Street - Garden Suite
‘Topeka, Kansas 66603
Tel: (785) 233-5887
Fax: (785) 233-2173,
‘Attomey for Petitioner
IN THE DISTRICT COURT OF SHAWNEE COUNTY, KANSAS
DIVISION 2
In the Matter of the Marriage of:
HAL RICHARDSON
and Case No. SN 96 D 217
CLAUDINE DOMBROWSKI
PETITIONER’S
DOMESTIC RELATIONS AFFIDAVIT
1 PETITIONFR’S: —9-9-60. 510-170-4518
Date of Birth Social Security Number
PETITIONER'S ADDRESS: 1727 Shawnee Heights Rd., Tecumseb, Kansas 66542
2. RESPONDENT'S: 4-10-65 511-74-9645
Date of Birth Social Security Number
RESPONDENT'S ADDRESS: P.O. Box 984, Manhattan, Kansas 66505
3. DATEOFMARRIAGE: Divorced
4. NUMBER OF MARRIAGES: 2 2
Petitioner Respondent
5. NUMBER OF CHILDREN OF THIS MARRIAGE: 1
6. NAMES, SOCIAL SECURITY NUMBERS, BIRTHDATES AND AGES OF
MINOR CHILDREN OF THIS MARRIAGE:
Name Soc. Sec. No. Date of Birth Age
Rikki A. Dombrowski $13-11-4344 1212-946APR-02-01 HON 09:25 HOFFMANLAWOFF ICES FAK NO, 7852932173 P03
‘NAMES, SOCIAL SECURITY NUMBERS AND AGES OF MINOR CHILDREN
OF PREVIOUS MARRIAGE AND FACTS AS TO CUSTODY AND SUPPORT
PAYMENTS PAID OR RECEIVED, IF ANY:
Name ‘Name of Custodian SS# Date of Birth Support Paid
3-Adults Petitioner
IF THIS IS A POST DIVORCE MATTER, PLEASE LIST ANY NAMES, SOCIAL,
SECURITY NUMBERS, AND AGES OF MINOR CHILDREN FROM YOUR
PRESENT MARRIAGE OR RELATIONSHIP:
Name SS.Number Dateof Birth Ase
NA
PETITIONER IS EMPLOYED BY: Minuteman Solar Film (self-employed)
Topeka, Kansas
Topeka Vinyl Top Center
Topeka, Kansas
RESPONDENT IS EMPLOYED BY: Unemployed
with monthly income as follows:
WAGE EARNER, Patti Respondent
Gross Income
Other Income
Subtotal Gross Income
Federal Withholding
Federal Income Tax
Railroad Retirement
OASDHI
Kansas Withholding
Subtotal Deductions
Net Income
(Line A.3 minus Line A.8)
‘SELF-EMPLOYED Petitioner ‘Respondent
Gross Income from
Self-Employment $2,219.00
Other Income
Subtotal Gross Income
Reasonable Business Ex,
(itemize on atached exhib)
Self-Employment Tax
Estimated Tax Payments
(Claim ___ exemptions)
Federal Income Tax
era usury
3 ay peRAPR-02-01 MON 09:25 HOFFMANLANOFF ICES FAX NO, 7852332173 P04
3
8. Kansas Withholding
9. Subtotal Deductions
10. Net Income
(Line B.3 minus Line B.9)
PAY PERIOD: Varies
PETITIONER RESPONDENT
10. WORK RELATED CHILD CARE EXPENSES:
uh
12.
Weekly Expense - $100.00 Name and Address of Provider
Tiffany M. Richardson
1727 Shawnee Heights Rd.
Tecumseh, Kansas 66542
HEALTH INSURANCE EXPENSES: Family Coverage _X__ Yes
Name of Health Insurance Plan, Name and Address of Administrator:
Continental General Ins. Co.
‘Which party pays for family health insurance coverage? _X Petitioner
Monthly cost of health insurance $1116.06: monthly cost of dental insurance $.
Persons Insured on Family Plan:
Petitioner & Minor Child
Wate he ncease cos fo providing family plan oer the party's cos of single plan
coverage? $81.00 Any additional cost for number of dependents, if so, how much?
8 5
ss
Amount of annual deductible
% coinsurance
THE ASSETS OF THE PARTIES ARE:
Ownership
dointor Date Date of
‘Asset _and Ownership individual Acquired Matkel Value ‘Yaluation
Checking Accounts:
Commerce Bank ——(Ind.-Pet.) Unknown
Savings Accounts and Certificates of Deposit:
NA
‘Cash on Hand:
Petitioner
RespondentAPR-02-01 NON 09:26 HOFFMANLAWOFF ICES FAX NO, 7852332173 P06
***PARAGRAPHS 12 D. THROUGH 12 K., 13, 14, 15 and 16 NEED NOT BE
ANSWERED IN POST JUDGMENT PROCEEDINGS***
D.
.
Fialasee Receaene Savings! i neSavines
County
‘Appraiser Value
LIFE INSURANCE: Cash Value
MOTORCYCLES:
Make/Model VIN Fair Vi:
BOATS, TRAILERS OR CAMPERS: Value
HAND OR POWER TOOLS:
JEWELRY:
GUNS:
CAMERA EQUIPMENT:
ANTIQUES:
HOUSEHOLD GOODS & FURNISHINGS:
PERSONAL INJURY OR WORKER’S
‘COMPENSATION CLAIMS:
ALL OTHER ASSETS NOT
INCLUDED ABOVE:
TOTALAPR-02-01 HON 09:26 ‘HOFFNANLAWOFF ICES FAX NO. 7852332173 P08
13.
LIST_ALL LIABILITIES OF THE PARTIES: (Include mongages and
indebtedness to banks, individuals, loan companies or on credit accounts. Indicate acrual
balance does of the date his document is prepared If secured, tate the propery which
secures the loan.)
Amount of
Creditor Balance Monthly Payment — Security
TOTAL
14. RECAPITULATION:
Assets
A. Checking Accounts
B. Savings Accounts
eh cam
D. Retirement Plans
E. Real Estate
F. Marketable Securities
G. Accounts Receivable
H. Life Insurance
I. Mise, Personal Property
TOTAL VALUE
OF ASSETS
15.
16.
iti
A. Real Estate Mortgages
B. Auto Loans
C. Total Other Debt
TOTAL LIABILITIES
PARTIES’ NET WORTH
(Assets Minus Liabilities)
IDENTIFY THE PROPERTY, IF ANY, OWNED BY EACH OF THE PARTIES PRIOR
‘TO MARRIAGE OR ACQUIRED DURING MARRIAGE BY FAMILY GIFT, WILL
OR INHERITANCE.
LIST ANY PAYMENT OR CONTRIBUTIONS RECEIVED OR PAID BY THE
PARTIES: (Specify source or payee and the amount denoting (+) if income and (-) if
payment.)
Source itioner RespondentAPR-02-01 HON 09:27 HOFFHANLAWOFF ICES FAX NO. 7852332173 P07
17. THE MONTHLY EXPENSES OF EACH PARTY ARE:
LIVING EXPENSES:
(Indicate with asterisk all figures which are estimated rather than actual)
Petitioner Respondent
OEM
A. House payment, rent or mortgage $540.00
B. Food 280.00
C. Utilities:
Trash Service 11.00
Newspaper
Te 40.00
Gas and Lights 75.00
Water 15.00
Cable 47.00
D. Insurance:
Lif
Health 116.00
Car 30.00
House
Other
E, Uninsured Health
F. Child Care (baby-sitting) 433.00
G. Clothing 50.00
H. School expenses 20.00
1, Haircuts and beauty 20.00
J. Carrepair 25.00
K. Gas and oil 75.00
L. Personal Property Tax 10.00
‘M. — Miscellancous (specify)
Recreation 50.00
TOTAL $1,807.00APR-02-01 MON 09:27 HOFFMANLAWOFF ICES: FAX NO, 7862332173 P.08
STATE OF KANSAS )
dss:
COUNTY OF SHAWNEE )
have read the above affidavit and to the best of my knowledge and belief the information
is accurate and complete.
S01
Subscribed and sworn this af day ot Bp 2001
‘My appt. expires:APR-02-01 MON 09:28 HOFFMANLAWOFF ICES FAX NO. 7852332173 P08
CERTIFICATE OF SERVICE
Thereby certify that on this Zeee/ day of April, 2001, a true and correct copy of the above
‘and foregoing Petitioner's Domestic Relations Affidavit was faxed to the following:
Clerk of the District Court
‘Shawnee County Courthouse
FAX NO. 291-4911
Lori Yockers
Administrative Hearing Officer
FAX NO. 291-4917
Harry Moore
Court Services
FAX NO. 291-4959
Leonard Robinson
FAX NO. 233-7061
INALD R. HOFFMAN