Child Support Enforcement Division Financial Affidavit

Instructions: 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

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.

B. CHILDREN

1. List all of your natural and adopted children (do not include stepchildren)

Attach a copy of any order requiring child support to be paid for these children.

2. 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.

3. Do you receive reimbursement for day care expenses? No Yes $

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

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.

$ 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.

C. EMPLOYMENT

1. List your current or most recent employer(s) first and your past two employers:

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:

D. INCOME

1. List all income which you receive or have received in the last 12 months.

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.

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 .

Print Name:

Residing at:

My Commission Expires: