Fill and Sign the Department of Public Health and Human Services Child Support Enforcement Divisionfinancial Affidavit Financial Affidavit Form

1CS-404.6A (Rev. 11/98)MONTANA CHILD SUPPORT GUIDELINES FINANCIAL AFFIDAVIT INSTRUCTIONS FOR COMPLETING THIS FORM: It must be signed and notarized. Provide complete information, attaching additional pages if needed. If a question or statement does not apply to you, DO NOT LEAVE BLANK. Instead, mark it as "Not Applicable" or ?N/A.” Your social security number is requested on this form. No state law requires you to give this number. Courts and administrative agencies use this number to track cases and to apply payments to the correct case. A. PERSONAL INFORMATION Name:Social Security #: Home Address:Telephone #: Date of Birth: Mailing Address: Case/Cause #: Driver’s License #: What is your tax filing status? ~ Single ~ Married, joint ~ Married, separately ~ Head of Household List the people you claim as tax exemptions If you are married and file taxes jointly, please provide your current spouse’s annual income so that tax credits may be calculated accurately. $ Did you finish high school?~ Yes ~ No If no, indicate highest grade completed: List all schools attended following high school. Include training school, college or university, trade school. School NameCourse of StudyCompletion DateDegree/Diploma B. CHILDREN 1.List all of your natural and adopted children (do not include stepchildren) Child's Full NameDate of Birth Month/Day/Year Who does child live with?Are you ordered to pay support for this child? ~ No ~ Yes $ amount/month ~ No ~ Yes $ amount/month ~ No ~ Yes $ amount/month ~ No ~ Yes $ amount/month ~ No ~ Yes $ amount/month ~ No ~ Yes $ amount/month ATTACH A COPY OF ANY ORDER REQUIRING CHILD SUPPORT TO BE PAID FOR THESE CHILDREN. 22.Complete the table below for all expenses you pay and benefits you receive on behalf of all children shown in the previous table. Attach proof for the items listed below. Do NOT list amounts paid by other parent. Child's First NameAnnual Day Care CostsAnnual Unreimbursed Medical ExpensesAnnual Dependent's Benefits Received*How many days does child spend with you per year?**Annual Miles Driven for Long Distance ParentingOther Transportation Costs for Long Distance Parenting*** * For example - Social Security Benefits ** The majority of a 24 hour period the children are in your control *** Do not include lodging, food and entertainment 3Do you receive reimbursement for day care expenses? ~ No ~ Yes$ / month reimbursement 4.If any of the children listed above have ongoing medical expenses, please describe. 5.Do you have health insurance available to you through employment or other group?~ No ~ Yes If no, skip to Section C. Name everyone who is covered by this policy: Regardless of whether your children are covered, complete the following: Insurance Co. Name: Address: Policy Number: Certificate Number: $ Total cost of health insurance premium per month, including your children (whether or not you andchildren are currently enrolled). $ Adult’s portion of premium. $ Child(ren)’s portion of premium. $ Portion of premium to be paid by you each month. $ Portion of premium to be paid by employer or other group each month. 3C. EMPLOYMENT 1. List your current or most recent employer(s) first and your past two employers: Employer’s Name, Address, and TelephoneDates of EmploymentAverage Hours Worked and Current or Ending PayP-Permanent T-Temporary S-Seasonal From To hours/week pay/hour From To hours/week pay/hour From To hours/week pay/hour 2. What kind of work do you/did you do for your employer(s)? 3.Do you belong to a union? ~ No ~ Yes If yes, name of union local, address, and amount of monthly dues: 4.Do you receive workers' compensation or occupational disease benefits? ~ No ~ Yes If no, are you currently seeking workers' compensation benefits or occupational disease benefits? ~ No ~ Yes If yes, who pays those benefits and what is your claim number: 5. Are you currently receiving unemployment benefits? ~ No ~ Yes If yes, name of state or agency paying those benefits: 6.If unemployed or employed part-time, have you made any efforts to find full-time employment? ~ No ~ Yes If not, why not? If yes, describe your job search: 4D. INCOME 1.List all income which you receive or have received in the last 12 months. Income SourceAnnual AmountIncome SourceAnnual Amount Gross Wages Public Assistance UnemploymentVeterans’ Disability Workers' CompensationSpousal Support Social Security BenefitsContract Receipts RetirementRental Income Interest/Dividend IncomeFringe Benefits/Bonuses ReimbursementsProfit (Loss) from Self-employment Educational GrantsOther: Do you receive any non-cash benefits from your employer, such as housing, groceries, meat, car or truck, utilities, phone service? ~ No ~ Yes If yes, describe the non-cash benefit you receive, how often you receive it, and the value of the benefit: 2.If you are self-employed, describe your self-employment activities: How many hours per week do you spend engaged in self-employment activities? Is your self-employment the primary source of your income for meeting your living expenses? ~ No ~ Yes 3. Have you, in the past 12 months, received any prize, award, settlement or other one-time cash payment? ~ No ~ Yes If yes, describe the payment, including the amount and its present location and value. 4. ATTACH COPIES OF LAST THREE MONTHS PAY STUBS. ATTACH COMPLETE COPIES OF PRECEDING TWO YEARS FEDERAL INCOME TAX RETURNS. Include all schedules filed and W-2 forms. If you do not have pay stubs or W-2 forms, provide employer's statement. E. DEDUCTIONS AND EXPENSES 1.List deductions from gross wages, including costs for required uniforms or work-related equipment. Attach pay stubs and proof of expenses. DEDUCTIONAMOUNTHOW OFTEN PAID? Federal Income Tax State Income Tax FICA and Medicare Mandatory Retirement Required Work Related Costs 5 2.Do you have any extraordinary medical expenses for yourself, not reimbursed by insurance, your employer, or another, which are necessary for you to maintain your health or your earning capacity? ~ No ~ Yes If yes, list yearly expenses and attach proof. 3.Please list any necessary expense you pay for in-home nursing care to enable you to work and for whom the expense is paid: 4.List employment related expenses not shown elsewhere: 5.Please attach a list of monthly expenses if you feel it is important to show your financial situation. F.ANTICIPATED CHANGES/ADDITIONAL COMMENTS 1. Please list any changes you expect in your or your child(ren)’s circumstances during the next 18 months which would affect the calculation of child support? 2.ADDITIONAL COMMENTS: VERIFICATION: You must sign this in front of a Notary Public. STATE OF ) :ss COUNTY OF ) I declare, subject to penalties for perjury and false swearing, that I have read the foregoing affidavit and that the information contained in it and all attachments to it is true and correct to the best of my knowledge, information and belief. DATED this day of , in the year of . Affiant SUBSCRIBED AND SWORN TO before me, a Notary Public for this State on the date and at the place written above. (SEAL)NOTARY PUBLIC Print Name: Residing at: My Commission Expires: