FILED BY CLERK 4.8. B STRICT COURT Donald R. Hoffiman (Ks 07332) Jeon. Hofinan (KS. 17637) th TOPEKA RS. HOFFMAN & HOFFMAN CoreFirst Bank & Trust Building 004 NOV. 13 A % 34 100 E. 9® Street — 3rd Floor East Topeka, Kansas 66612 Ph. (785) 233-5887 Fax (785) 233-2173 Attorneys for Petitioner IN THE DISTRICT COURT OF SHAWNEE COUNTY, KANSAS DIVISION 13 In the Matter of the Marriage of: HAL RICHARDSON, Petitioner, and Case No. 96 D 217 CLAUDINE DOMBROWSKI, Respondent. ‘MINI DOMESTIC RELATIONS AFFIDAVIT of HAL RICHARDSON lL Your Name: Hal Richardson Residence: 1727 Shawnee Heights Rd., Tecumseh, Kansas 66542 1960 XXX- XX-4518 Year of Birth Social Security Number 2. Names, SS#, birth dates, and ages of minor children of the marriage/relationship: Name SS Number Year of Birth Age Rikki Dombrowski XXX-XX-9645 194 4 3. Names, SS#'s, and ages of minor children of previous marriage/relationships and facts as to custody and support payments paid or received, if any. Name ‘Name of Custodian SSNumber Year of Birth Support Pd/Received N/A10. ‘You are employed by: Name: Address: Monthly Income: A. Wage Eamer, Gross income B. Self-employed, Gross Income $2,267.00 Reasonable Business Expense Self-Employment Tax Work Related Child Care Expenses: N/A A. Weekly Summer expense ‘Name and Address of Provider $ B. Weekly School Year Expense ‘Name and Address of Provide $ Father/Mother provides Health Insurance for child(ren). A ‘Name and Address of Health Insurance Plan: Blue Cross Blue Shield of Kansas B. Persons insured on Plan: Rikki Dombrowski C. Monthly cost of health insurance: $340.00 Monthly cost of dental insurance: Monthly cost of vision insurance: Monthly cost of drug prescription insurance: Increase cost of adding child(ren) to the plan: Father claims child for income tax purposes: You file taxes: single __X_ Head of Household Joint Other Child Support Adjustments requested: Long distance Parenting time Adjust. Parenting Time Adjustment Tncome Tax Adjustment Special Needs ‘Agreement Past Minority X_Overall Financial Condition Attached is: Current Pay Stub X__Last Year's Tax Form __W-2 Written Proof of Day Care Cost Written Proof of Insurance Costs Other I declare under penalty of perjury under the law of the State of Kansas that the foregoing is true, correct and complete. Executed on the YEP day OF(\oembs, 2009. HAL LeeUSindividual income Tax Return Fare ow J -Dee 31,2008 oo form 1040 Label Seeanne Soeis = Youre open A your ssNis) above. A me 8 Checking box bet wl not eased Change your tx ort Brcton Gh hae TU JHU spoon FAIRS wa STO DOTS MT TREDSGETAT— >| | You [| Spouse sro 7 Tiltestiomn er amperes Fling 2 [area tng ond (even ony one had income) Rese a ee Status} Cliccrmyeprn cur gaar tere > eee wit rare hare PP 5 |_| Qualifying widow(er) with dependent child (see page 16) Exemptions * iYousat Weave cn cainyorens Gipson, Ort ec ota oo b [spouse cece tmsepentae —€ Dependent bean = Frtnane tana Seater i 1 pat maters cy Teal rarer femora dammed 7 o> ao Mts: 7 Wipes, sare, te, ee. Alach Forni) 2 Income Taaie eres Atach Sede B frequred fguacnromis) "S Tecarempinarent Donandse sot tach Forme Crnay ddends. Ata Sched Bf required W.2G and Qualified dividends (see page 21) +--+ +--+ + A {00 te Tame 20 oa of en nes T= = [10 | M1 Amonjrocehed wsscutrescresserse Soe 12 eas nome or ons). Ach Sede CorCEZ +. .s ssc oes oes een 2aa7 18. Capital gain or (oss. Attach Schedule Dif required, Ina required, checkhere = [] [13 Hyoudidnot 46 Omer guia or eaten), tach Fo A707 ses sre sresteesretce ses e te] ¥ 6e Advtutions = + «+ «| 184 1 Tacable aunt on pag 25 [18 160 Penatne and ents = - [Ya 2 Taxable aunt ws ae 26 | 180 47 Rectal ret estat, yates, pnertipa 8 coporaons, Wit te Mach Schedule =» =| ¥7 Tada $8 Fermincome oro). Atnch Schedule = == vee fae 0s Greapinen capemn een ee ere ies 200 Soclseoutybenats » +| 208 Taxable aunt a ape 26 | 200 ‘21 Other income. GAMBLING WINNINGS. 4,800 x 2 Pitman agi aie RRA Tamera par 33-290 i Ehucalor expense ec page 28) == == [a8 ; Adjusted 2 cotta upweat cnet pte wt Gross ‘eon goer oe san he 0827 | Income «25 -_‘Heetlvsavngs acount edcon. Atach For 8880. == -| 25 28° Moving exgerece. AlachFom 3003 = === «==. + [28 | 27 Onetat of set-enplowmentie Atach Scheaue SE «=. 27 Zoi | 28. Sateplayed SEP, SIMPLE, nd uated lana == + = -[ 2B 29 Sal-employe hath iarance deduction eee page 29) -[ 38 7080 | 30° Penaty neath wthirml savage sree es +++ 5 [30 : 246. Almony pa b Rechlents SSN b si] 32 IRA deduction (see page 30) - sree eee eee sof 32 33 Sudertioan terest deducon (eee page 39) «+++ ++ «3B 34 Tuton and tes deducion AtachFom 8817 «=== [3a 38 Danese production aces deducton tach Form 8803 -[ 36 36 Aadines 29 trough Siaand Styough 36 +--+ sree 0ST PTET 6,093 ‘37_Sublract line 36 from line 22. This is your adjusted gross income _- - Serena 7 27,19 For Diaclosure, Privacy Act, and Paperwork Reduction Act Notes, eve page 8. ea "Form 4040 (2008)