Fill and Sign the Depose and State as Follows Form

Affidavit of Imputed Income July 2014 Page 1 of 4 STATE OF WYOMING ) IN THE DISTRICT COURT ) ss COUNTY OF ________________ ) _______________ JUDICIAL DISTRICT Plaintiff:____________________________, ) Civil Ac tion Case No. ___________ (Print name of person filing) ) ) vs. ) ) Def endant: __________________________ . ) (Spouse) (Print name) AFFIDAVIT OF IMPUTED INCOME ___________________________________________________________________ (Only use this form if you are unable to get the other party to complete a Confidentia l Financial Affidavit .) I, _____________________, of lawful age, first being duly sworn upon my oath, (print name) depose and state as follows: 1. I am the Plaintiff OR Defendant in the above -captioned matter. 2. I am no t able to get a Confidential Financial Affidavit from the other party because: . 3. The other party has certifications, degrees, education or training relevant to his/her employability as follows: ___________________________________________ _______ _________ __ _ _______________________________________________________________ 4. Explain , to the best of your knowledge, the other party’s work history or other sources of income for the previous two years: 5. His/her inco me for this year is unknown, as she/he has not provide d financial information and has failed, neglected or ot herwise refused to file a Confidential Financial Affidavit . 6. I do OR do not have copies of the last two year’s income tax returns showing the amount earned by Plaintiff OR Defendant . ATTACH ANY TAX Affidavit of Imputed Income July 2014 Page 2 of 4 RETURNS, W -4s, CHECK STUBS OR OTHER INFO RMATION ABOUT THE OTHER PARTY’S INCOME TO THIS DOCUMENT. If you have information about the other parent’s previous or current employment by area and occupation, you may be able to get information regarding wages by visiting the U.S. Department of Labor Bureau of Labor Statistics website for wage information by area and occupation http://www.bl s.gov/bls/blswage.htm. Attach any relevant documentation to this Affidavit. 7. Plaintiff’s OR Defendant’s income i s based on him/her being paid : ______ weekly ______ every two weeks ______ twice per month (i.e. 1st and 15 th of every month) ______ monthly _______annually Convert annual, bi - weekly, bi -monthly, and weekly amounts to monthly amounts below . ** Gross income (includes tips, commission and bonuses ). Monthly amounts are calculated by multiplying w eekly amount by 52 and dividing by 12; multiplying bi -weekly amounts by 26 and dividing by 12; and multiplying semi -monthly amounts by 24 and dividing by 12; annually by dividing by 12. If only the “gross income” is known, multiply that number by .25 (or other number if instructed by Court) and then subtract that amount from the gross to arrive at the net monthly income. If the other party has a history of only working for minimum wage or less, and is capable, to your knowledge of working 40 hours/week, the court may impute his/her income at $ 1,141.25 net monthly for a noncustodial parent and $1,185.67 net monthly for a custodial parent . You may call your local child support enforcement office for more information on imputing a custodial or non -custodial p arent’s wage. Federal minimum wage is $7.25/hour as of July 1, 20 12 . 8. Plaintiff’s OR Defendant’s estimated gross income (before deductions) is: $_____________ per month , to the best of my information and belief . "Inco me" means any form of payment or return in money or in kind to an individual, regardless of source. Income includes, but is not limited to wages, earnings, salary, commission, compensation as an independent contractor, temporary total disability, permanent partial disability and permanent total disability worker's compensation payments, unemployment compensation, disability, annuity and retirement benefits, and any other payments made by any payor, but shall not include any earnings derived from overtime wo rk unless the court, after considering all overtime earnings derived in the preceding twenty -four (24) month period, determines the overtime earnings can reasonably be expected to continue on a consistent basis. In determining income, all reasonable unreim bursed legitimate business expenses shall be deducted. Means tested sources of income such as Pell grants, aid under the personal opportunities with employment responsibilities (POWER) program, food stamps and supplemental security income (SSI) shall not b e considered as income . Gross income also means potential income of parents who are voluntarily unemployed or underemployed . "Net income" means income as defined in the box above , less personal income taxes, social security deductions, cost of dependent health care coverage for all dependent children, actual payments being made under preexisting support orders for current support of other children, other court -ordered support obligations currently being paid and mandatory pension deductions. Payments towa rds child support arrearage shall not be deducted to arrive at net income. Affidavit of Imputed Income July 2014 Page 3 of 4 9. Based on the previous work history and /or income , Plaintiff OR Defendant has the ability to earn a net ( after appropriate deductions ) monthly in come of $___________ and said amount should be used to calculate child support under the presumptive child support guidelines. * If the other party has a history of only working for minimum wage or less, and is capable, to your knowledge of working 40 hou rs/week , the court may impute his/her income at $1,141.25 net monthly for a noncustodial parent and $1,185.67 net monthly for a custodial parent . 10. Further your affiant sayeth naught. DATED this _______day of _______ 2 0_____ . Signature Prin ted Name: Address: Phone Number: STATE OF_____________ ) ) ss. COUNTY OF___________ ) The foregoing instrument was subscribed and sworn to before me by ____________________________ this ________ day of _____________, 2 0 Witness my hand and official seal. ________________________ Notarial Officer My commission expires: Affidavit of Imputed Income July 2014 Page 4 of 4 C E R T I F I C A T E O F S E R V I C E I certify that on (date) the original of this document was filed with the Clerk of District Court; and, a true and accurate copy of th is document was served on the other party by Hand Delivery OR Faxed to this number OR by placing it in the United States mail, postage pre -paid, and addressed to the following : (Print Other Party’s/Other Party’s Attorney’s Name and Address) TO: ______________________________________ ______________________________________ ______________________________________ Your signature Print name