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 1212-946APR-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 peRAPR-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 RespondentAPR-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: TOTALAPR-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 RespondentAPR-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 $1,807.00APR-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