Affidavit of Financial Means

AFFIDAVIT OF FINANCIAL MEANS

IN THE CIRCUIT COURT OF COUNTY, ARKANSAS
(Domestic Relations Division)
Division

v.

Defendant

Name: , being duly sworn, says under penalty of perjury, that he/she has prepared or approved this financial statement, and that the following information and attachments (including income verification as required by page 7) are complete, true, and correct.

Subscribed and sworn to before me on this day of of .

Notary Public

My commission expires: .

MY INCOME

1. How often are you paid?

2.* Net Pay (Take-home after allowable deductions):

*Complete worksheet on next page to determine Net Pay for calculating child support.

NET PAY WORKSHEET

(If more than one employer, fill out and attach multiple copies of this worksheet).

EMPLOYER:

Address: Telephone #:

3. Gross Wages per pay period:

ALLOWABLE DEDUCTIONS UNDER STATE LAW

A. Federal Income Taxes Withheld:

B. State Income Taxes Withheld:

C. F.I.C.A. (Social Security) or Railroad Retirement:

D. Medicare:

E. Health Insurance (only the portion paid for children in this case as required by page 7):

F. Court-ordered child support for other children not involved in this current case:

G. TOTAL Allowable Deductions:

3.H Subtract TOTAL Allowable Deductions from Gross Wages = NET PAY

OTHER INCOME

4. Other income

4.1 Bonuses or incentive pay not reflected on page 2: Source: Frequency:

4.2 Other court-ordered income such as alimony/child support paid to you: Source: Frequency:

4.3 Payments from a settlement or annuity: Source: Frequency:

4.4 Regular gifts from relatives or friends: Source: Frequency:

4.5 Investment income such as rent payments to you: Source: Frequency:

4.6 Stock dividends or bond payments: Source: Frequency:

4.7 Regular payments to you or on your behalf from a Trust: Source: Frequency:

4.8 Other: Source: Frequency:

4.9 TOTAL OTHER ANNUAL INCOME:

OTHER AVAILABLE FUNDS

5. Assets

5.1 Cash on hand, and in bank accounts: Source:

5.2 Trust fund assets held on your behalf: Source:

5.3 Stocks, bonds, mutual funds: Source:

5.4 Other (i.e. 401-K, retirement, etc): Source:

5.5 TOTAL:

MY CURRENT MONTHLY EXPENSES

6. Expense items

a. Rent/house payment

b. Gas, water, trash, & electricity

c. Telephone

d. Internet

e. Media Services, i.e. Cable/Satellite, etc.

f. Child care

g. Food

h. Union dues

i. Pension plan

j. 401(k) payments

k. Garnishments

l. Cigarettes

m. Alcohol

n. Health Insurance

o. Non-covered medical (including medicine)

p. Life insurance

q. Car payment

r. Car Insurance

s. Car fuel and maintenance

t. Lawn care

u. Charitable giving

v. Household Expenses

w. Dry cleaning

x. Other:

y. Other:

z. TOTAL:

* Place a check mark by all expenses which you are not currently paying.

MINOR CHILDREN

7a. Number of minor children I have with opposing party:

7b. Number of other minor children I have:

7c. Names of minor children involved in this case:

1. AGE

2. AGE

3. AGE

4. AGE

CREDITORS & DEBTS

8. Debts in the names of BOTH PARTIES are:

a. Creditor: Total amount owed: Monthly payment:

b. Creditor: Total amount owed: Monthly payment:

c. Creditor: Total amount owed: Monthly payment:

d. Creditor: Total amount owed: Monthly payment:

e. Creditor: Total amount owed: Monthly payment:

f. Creditor: Total amount owed: Monthly payment:

g. Creditor: Total amount owed: Monthly payment:

Totals: Total amount owed Monthly payment

9. Debts only in my name:

a. Creditor: Total amount owed: Monthly payment:

b. Creditor: Total amount owed: Monthly payment:

c. Creditor: Total amount owed: Monthly payment:

d. Creditor: Total amount owed: Monthly payment:

e. Creditor: Total amount owed: Monthly payment:

Totals: Total amount owed Monthly payment

10. Debts only in the name of the other party:

a. Creditor: Total amount owed: Monthly payment:

b. Creditor: Total amount owed: Monthly payment:

c. Creditor: Total amount owed: Monthly payment:

d. Creditor: Total amount owed: Monthly payment:

e. Creditor: Total amount owed: Monthly payment:

Totals: Total amount owed Monthly payment

SUMMARY OF ABOVE DEBT TABLES

a. Joint Debts: Total Owed Total Monthly Payments

b. My Debts: Total Owed Total Monthly Payments

c. Other Party’s Debts: Total Owed Total Monthly Payments

ACKNOWLEDGEMENT OF RESPONSIBILITIES AND CONSEQUENCES

I, understand that I must comply with the following. I acknowledge and agree to each provision by initialing each paragraph below.

Both parties must complete and exchange this seven-page affidavit by providing to opposing counsel or pro se litigants within five days before hearing.

Both parties must supply the original notarized affidavit to the court.

If I am employed, I must attach copies of my last three paystubs to this affidavit.

If I am self-employed, I must attach copies of my last two federal and state tax returns, including all schedules, to this affidavit.

Before each court hearing where financial matters are at issue, I will review this document and provide updated information to the other party and to the court.

I understand that the cost of dependent health insurance coverage is the difference between self-only and self with dependents or family coverage or the cost of adding the child(ren) to existing coverage.

I understand that failing to comply with these provisions, or deliberately attempting to mislead the court or the opposing party, may result in my being held in contempt of court, being fined, being ordered to pay attorney’s fees, and/or being sentenced up to 6 months in jail, and that serious violations can result in prosecution for felony perjury—punishable by 3 to 10 years in prison.

I certify that I have reviewed this affidavit with my client and advised him or her of the importance of providing true, correct, complete answers and the required exhibits.

Form Revised 10/2016