WPC  =]2~[puZ$G!ܜS ޡB*GcP_;;}]vD'PHPGxQ*?g2;|*FNP A Ojhux--~%}!hTALA;q^}'<&2xԎy˜akE_rP R^#m)[1E4 P* E?5nȹC jX mhbpϱRކ\YI nM.CX P?"̖<pePFb ˍWq%;0T5gh%Sxt= X^ ͽxhA.};#hK' K϶$7"6Мpg#JҖ7Cv7=YpNl@'h`B/5Q4#&X?c;!7SĮ>$IH?ME@C ی<Um:nalM`#@UN %O 0:U U. 1k UF( U<n 1u 72 BQ ^ n wz 4~   f a m f a f a f a f a N( b* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * D5D D D B -y HP LaserJet 4,,,,,,0(9 Z6Times New Roman RegularX($USUS.,<6X9`(Courier$35;AGOW_e11.a.i.(1)(a)(i)1.a.<4 9Z .Courier New Regular\  `$Times NewRoman3#37=CIQYag1.a.i.(1)(a)(i)1)a) i)  d(. \-ȝ3|xTable_AUwTABLE AdTABLE B?TABLE CnTABLE DPage of & )!dxdx)Hairline d !USUS.,  _XqXXX8XXdd8LAWOFFICEOF  STACYL.ORTEGA,P.A.  LandmarkSquare \ 212NorthMarket,Suite306 2 Wichita,Kansas67202 X (316)2635900 . @ INTHEEIGHTEENTHJUDICIALDISTRICT   @ DISTRICTCOURT,SEDGWICKCOUNTY,KANSAS `  @ FAMILYLAWDEPARTMENT 6   INTHEMATTEROFTHEMARRIAGEOF0  ) 2 (#(#    `     h     )   ,  0 ` 0 ` (#` (#0 (# (#0h(#(#0h(#h(#0(#(#) (#(#    `     h     ) d     `  Petitioner,  0  ): (#(#    `     h     ) `  AND   `    0 h 0h(#h(#0(#(#)CASENO.6(#(#    `     h     )   ,  0 ` 0 ` (#` (#0 (# (#0h(#(#0h(#h(#0(#(#)(#(#    `     h     ) h    `  Respondent.  0  )>(#(# _______________________________  ) d PURSUANTTOCHAPTER60OF : KANSASSTATUTESANNOTATED  @ DOMESTICRELATIONSAFFIDAVITOF l @$򀀀 B 1.  Petitioner'sResidence:򀀀 >    `  Wichita,KS67  Ѐ  Petitioner's򀀀󀀀򀀀򀀀  󀀀_D.O.B._ԀSocialSecurity#HomeTelephone p    DriversLicenseNo._____________ F !   Birthplace򀀀 !B#   LevelofEducation򀀀 #%   RaceorEthnicity򀀀 J% '   (Optional,reportedtoVitalStatistics)  &p!( 2.  Respondent'sResidence:򀀀 '#*    `  󀀀Wichita,Kansas672 (#+   Respondent's򀀀򀀀򀀀 x)$, 󀀀_D.O.B._ԀSocialSecurity#HomeTelephone N*%-   DriversLicenseNo._____________ $+t&.  +J'/   Birthplace򀀀    LevelofEducation򀀀 \   RaceorEthnicity򀀀 X   (Optional,reportedtoVitalStatistics) . 3.  DateofMarriage:򀀀󀀀Place:򀀀     Datecouplelastresidedinsamehousehold򀀀 6   0  Whichpartywillremaininthemaritalresidenceona   2  temporarybasis?򀀀 (#(# 4.  NumberofMarriages:򀀀򀀀 d     `  PetitionerRespondent :    MaidenSurname򀀀 6 5.  Numberofchildrenofrelationship:򀀀  6.0  Names,SocialSecuritynumbers,birthdatesandagesof > childrenoftherelationship:d(#(#   Name ` Soc.Sec.#_D.O.B._󀀀AgeCustodian    򀀀     l    B 7.0  Names,SocialSecuritynumbers,andagesofminorchildren > ofpreviousmarriageandfactsastocustodyandsupport  paymentspaidorreceived,ifany:(#(#     Name `     h   Soc.Sec.#DateofBirth󀀀Age F !   򀀀򀀀 !l" 0  HaveanyofthesechildrenresidedoutsideofSedgwick @  "$ Countywithinthepast5years?򀀀Ifso,provide @!  #% dates,addresses,andnamesofpersonswithwhomthey  t$& resided.򀀀J% '(#(# 0  Havethereeverbeenanycustodyproceedingsorchild  &F") supportproceedingswithregardtothesechildren?򀀀 '#* Ifso,providedate,location,andcasenumber.򀀀 (#+ Ѐx)$,(#(# Ѐ `  N*%- 8.0  Petitionerisemployedby:򀀀$+t&.(#(#   Nameandaddressofemployer:򀀀 +J'/    `    󀀀 h     Wichita,Kansas    Phone    Respondentisemployedby:򀀀 \   Nameandaddressofemployer:򀀀 2    `    󀀀 h      X   Phone . 0  withmonthlyincomeasfollows: (#(# #XXXXq=#A.WageEarner0 0 (# (#0h(#(#Petitioner0h(#h(#0p(#(#0p(#p(#0 (#(#Respondent0 (# (#0@ x(#x(#0@ x(#x(#0@ x(#x(#0@ x(#x(#0@ x(#x(#0@ x(#x(#0@ x(#x(#0@ x(#x(#0@ x(#x(#6   (# (# * ddd Xdd Xdd X(#(#,( dd ,( dd#R,( dd#R+  " r " r 1.GrossIncome               2.OtherIncome  V    V    V  3.SubtotalGrossIncome            4.Withholding  V    V    V  5.FederalIncomeTax         6._OASDHI_  V   V   V 7.KansasWithholding         8.SubtotalDeductions  V    V!   V" 9.NetIncome  #   $  %  B.SelfEmployed0 0 (# (#0h(#(#Petitioner0h(#h(#0p(#(#0p(#p(#0 (#(#Respondent0 (# (#& (# (# * d d( dd ( ( dd#R( ( dd#R(  (#(#,( dd ,( dd ,( dd +  z'z 1.GrossIncome  .(   .)   .* 2.OtherIncome  ^+   ^,   ^- 3.SubtotalGrossIncome  ..   ./   .0 4.ReasonableBus.Expenses  ^!1   ^!2   ^!3 5.SelfEmploymentTax  ".4   ".5   ".6 6.EstimatedTaxPayments  ^$7   ^$8   ^$9 7.FederalIncomeTax  %.!:   %.!;   %.!< 8.KansasWithholding  ^'"=   ^'">   ^'"? 9.SubtotalDeductions  (.$@   (.$A   (.$B 10.NetIncome  ^*%C   ^*%D  ^*%E XqXXXPayPeriod: Petitioner:򀀀Respondent:򀀀 P,'F Ї9.  Theliquidassetsofthepartiesare:     `     h   0  0p(#(#0p(#p(#0 (#(#Jointor (# (#    `     h      p     Individual \    `     h   Item  Amount    (Specify) 2 A.  CheckingAccounts: h  .   򀀀  򀀀         򀀀  򀀀       B.  SavingsAccounts: 6     򀀀        \  C.  Cash      ` (Petitioner) h 򀀀 p       ` (Respondent) h 򀀀 p  :  D.  Other 6   򀀀       10.0  Themonthlyexpensesofeachpartyare:(Pleaseindicate h withanasteriskallfigureswhichareestimatesratherthan > actualfigurestakenfromrecords.)d(#(# I.  #XXXXq'#Xf|XXX :  (43 * d d( dd ( ( dd ( ( dd (  (#(#,( SJ,( SJ#R,( SS#R+  6 ' 16SDA 2 Items 2 #!D  2SDA Petitioner 6 #D  6SDA Respondent N ?'D3 1   1NSeHousePaymentorRent ; ,!  ; ? ,!e3  ?Se N ?'3 1   1NS,|)Food ; ,!,|  ;S,|) ? ,!,| 3  ?S,|) N ?',|!3 1   1NSMTrashService ; ,!"  ;SM ? ,!#3  ?SM N ?'$3 1   1NSdNewspaper ; ,!d%  ;Sd ? ,!d&3  ?Sd N ?'d'3 1   1NS 5 Telephone ; ,! (  ;S 5  ? ,! )3  ? N ?'5 *3 1   1NS!L!Water ; ,!!L+  ;S!L! ? ,!!L,3  ?S!L! N ?'!L-3 1   1NSp##mGas ; ,!p#.  ;Sp##m ? ,!p#/3  ?Sp##m N ?'p#03 1   1NS$4 $Electricity ; ,!$4 1  ;S$4 $ ? ,!$4 23  ?S$4 $ N ?'$4 33 1   1NSX&!&U!Cable ; ,!X&!4  ;SX&!&U! ? ,!X&!53  ?SX&!&U! N ?'X&!63 1   1NS'#y'"CellPhone ; ,!'#7  ;S'#y'" ? ,!'#83  ?S'#y'" N ?''#93 1   1NS@)$(=$InternetAccess ; ,!@)$:  ;S@)$(=$ ? ,!@)$;3  ?S@)$(=$ N ?'@)$<3 1   1NS*&a*%LifeInsurance ; ,!*&=  ;S*&a*% ? ,!*&>3  ?S*&a*% N ?'*&?3 1   1NS(,x'+%'HealthInsurance ; ,!(,x'@  ;S(,x'+%' ? ,!(,x'A3  ?S(,x'+%' N ?'(,x'B3 1   1NS41CarInsurance ; ,!4  ;S41 ? ,!43  ?S41 N ?'43 1   1NSUHouseInsurance ; ,!  ;SU ? ,!3  ?SU N ?'3 1   1NSlOther ; ,!l  ;Sl ? ,!l3  ?Sl N ?'l 3 1   1NS = UninsuredHealth ; ,!    ;S =  ? ,!  3  ?S =  N ?'  3 1   1NS T ChildCare ; ,! T   ;S T  ? ,! T3  ?S T  N ?' T3 1   1NSx % uClothing ; ,!x   ;Sx % u ? ,!x 3  ?Sx % u N ?'x 3 1   1NS <  2SchoolExpenses  <   2(Includinglunches) ; ,!,   ;S <  ? ,! < 3  ?S <  N ?' < 3 1   1NSP M HairCutsandBeauty ; ,!P   ;SP M  ? ,!P 3  ?SP M  N ?'P 3 1   1NS q CarRepairandMaintenance ; ,!   ;S q  ? ,! 3  ?S q  N ?' 3 1   1NS85GasandOil ; ,!8  ;S85 ? ,!83  ?S85 N ?'83 1   1NSYPersonalPropertyTax ; ,!   ;SY ? ,!!3  ?SY N ?'"3 1   1NS pAttorneyFees ; ,! p#  ;S p ? ,! p$3  ?S p N ?' p%3 1   1NSAEntertainment ; ,!&  ;SA ? ,!'3  ?SA N ?'(3 1   1NSX 2Miscellaneous(Specify) X)  ; ,!H*  ;SX 2 ? ,!X+3  ?SX N ?'X,3 1   1NSli Total ; ,!l-  ; ? ,!i.3  ?7-+i/3 1    7#XXXXf|.#X45XXXII.0  Monthlypaymentstobanks,loancompaniesorcredit z0 accounts:(Indicateactualorestimate,useasteriskfor B1 secured.) Z2(#(# *\ d d( SJ( ( SJ#R( ( SS#R( (#(#,` dd ,Fdd#,Fdd#R,Fdd#R,Fdd#+  $____I3I $Creditor -____] 4____ -When ] 5 Incurred - %!u6____ -Payment ] 7 Amount - %!u8  -Balance - ] 9  -Party: ] : Pet.or %!u; Resp. - !=<  - - I#=  - $I#>  $  I#?   I#@   I#A   $B   $C   $D   $E   $F   &Q!G   &Q!H   &Q!I   &Q!J   &Q!K   ]'"L   ]'"M   ]'"N   ]'"O   ]'"P   ( $Q   ( $R   ( $S   ( $T  ( $U  Totals: )(%U Petitioner__________ *&V Respondent__________ +'W Ї*\ d d` dd ` Fdd#FFdd#RFFdd#RFFdd#F\ (#(#,t dd ,dd#R,dd#R+   III.TotalLivingExpenses  d Petitioner d (Actualor , Estimated)   Respondent d (Actualor , Estimated)   A.TotalFundsavailableto P PetitionerandRespondent   (FromNo.8)       P    P  B.TotalNeeded(FromNo.  <  10I.andII.)       <    < C.Deficit   `    `    ` D.Amountofspousal l  supportand/orchild 4  supportrequested.  L    l   l   IV.  Paymentsofcontributionsreceived,orpaid,forsupportof  Z  others.Specifysourceandamount. "   Source    h     Petitioner  Respondent      򀀀  򀀀  FURNISHTHEFOLLOWINGINFORMATIONIFAPPLICABLE.  11.  Incomeandfinancialresourcesofchildren. }   Income/Resources h      p   Amount [!   򀀀 p   򀀀 J" 12.  Childsupportadjustmentsrequested. (x$    `     h      p Petitioner x Respondent V& Longdistancevisitationcosts0  0p(#(#$򀀀 x $򀀀4(p(#p(# Timespentwithnoncustodial  parent0 p $򀀀 x $򀀀 #)p(#p(# Incometaxexemption h   0  0p(#(#$򀀀 x $򀀀!*p(#p(# Specialneeds   0 h 0h(#h(#0(#(#0p(#(#$򀀀 x $򀀀"+p(#p(# Yourproposalregardingaccessbetweenthechild(_ren_)andthe $- noncustodialparent;weekday,weekend,holiday,andsummer: W% . 򀀀 F&!/ Ѐ '^"0 Ѐ ' Ѐ (#2 13.  Incometaxconsequenceadjustmentrequest,ifany: )$3 14.  Allotherpersonalpropertyincludingretirementbenefits k+&5 (includingbutnotlimitedtoqualifiedplanssuchasprofit 3,'6 sharing,pension,IRA,401(k),orothersavingstypeemployee  benefits,_nonqualified_Ԁplans,anddeferredincomeplans),and x ownershipthereof(jointorindividual),includingpoliciesof @ Insurance,identifiedastonatureordescription,ownership X (jointorindividual),andactualorestimatedvalue.      `     h      p     Jointor     `     h     Amount  Individual   򀀀  $     򀀀  $  򀀀   THEFOLLOWINGNEEDNOTBEFURNISHEDINPOSTJUDGMENTPROCEDURES. j   15.0  Listrealproperty(identifiedastodescription,ownership H  (jointorindividual)andactualorestimatedvalue.` (#(#    O  16.0  Identifythepropertyifanyacquiredbyeachoftheparties >  priortomarriageoracquiredduringmarriagebyawillor  inheritance.~(#(#    m 17.0  Listdebtobligations,includingmaintenance,notlistedin \ SectionIIabove,identifiedastonameornames,of_obligor_ $t or_obligors_Ԁand_obligees_,balancedueandrateatwhich < payable;and,ifsecured,identifytheencumberedproperty.(#(#   򀀀  18.0  Listhealthinsurancecoverageandtheright,pursuantto  _ERISA_Ԁ601608.29_a.s.c._Ԁ11611168(1986)tocontinued Z coveragebythespousewhoisnotamemberofthecovered "r employeegroup.:(#(#   򀀀 ) 19.  Listanyandallautomobiles.    Year ` MakeModel    Value  Possession    򀀀       !!   Ihavereadtheaboveaffidavitandtothebestofmy ;## knowledgebelievethattheinformationisaccurateandcomplete. $S$    `     h   _______________________________ %1!&    `    ,Petitioner & "'   SUBSCRIBEDANDSWORNTObeforemethis_____dayof򀀀, (#) _2003._ v)$*    `     h   _________________________________ e*%+    `     h   NOTARYPUBLIC T+&, MyAppointmentExpires:#XXXX45_P#