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Confidential Financial Affidavit Approved by the Wyoming Supreme Court (2012) Page 1 of 9 STATE OF WYOMING ) IN THE DISTRICT COURT ) ss COUNTY OF ________________ ) _______________ JUDICIAL DISTRICT Petitioner :___________________________ , ) Civil Action Case No. __________ (Print name of person filing) ) ) vs. ) CONFIDENTIAL ) Respondent :_________________________ . ) (Print name of other parent ) _______________________________________________________________________________ CONFIDENTIAL FINANCIAL AFFIDAVIT W.S. §20 -2-308 ________________________________________________ _______________________________ A financial affidavit must be completed by each parent. You must attach copies of your tax returns and W -2 forms for the most recent two years and a copy of the total amount of wages you have earned so far this year . Par ents who are self -employed must supply verified income and expense statements from their business for the two most recent years . THE UNDERSIGNED , ___ , hereby swears or affirms, (Print Your Name ) under pen alty of perjury, that the following answers are correct and complete. 1. Your N ame: (First, Middle, Last) ______________ ________________________________ Gender: Male Female 2. Your Present Address : ____________ ___________________________________________ City, State, Zip Code: _______________________________________________________ How long have you resided at this location? ______________________________________ Your Mailing Address (if different from abov e) ___________________________________ City, State, Zip Code: _______________________________________________________ 3. Your Home Phone Number : (___) _____________________________________________ Your Cell Phone Number : (____) ______________________________________________ PERSONAL INFORMATION Confidential Financial Affidavit Approved by the Wyoming Supreme Court (2012) Page 2 of 9 A Message Phone Num ber: ( ) 4. Your Social Security Number is: ______________________________________________ 5. Your Date of Bir th is: 6. Your Education is: ________years of high school; _________years of college; ________ years of trade school; _______ years other (list training) 7. List you r degree(s) or certificate(s): 8. List all chil d(ren) involved in this matter : Child’s Name Sex Birth Date Social Security No. Does this child live with you? M F Yes No M F Yes No M F Yes No M F Yes No M F Yes No Additional sheets of paper are attached (if needed) 9. List YOUR minor children (not named above) who live with you : Child’s Name Birth Date Social Security No. Additional sheets of paper are attached (if needed) Confidential Financial Affidavit Approved by the Wyoming Supreme Court (2012) Page 3 of 9 10 . List YOUR minor children (not named above) who do not live with you but for whom YOU are court -ordered to pay child support : Child's Name Birth Date Social Security No. Court and Date of Order Support/Month Arrears (Amount Past Due) Child's Name Birth Date Social Security No. Court and Date of Order Support/Month Arrears (Amount Past Due) Child's Name Birth Date Social Security No. Court and Date of Order Support/Month Arre ars (Amount Past Due) Child's Name Birth Date Social Security No. Court and Date of Order Support/Month Arrears (Amount Past Due) Additional sheets of paper are attached (if needed) 11 . Do you owe back child support (arrears) in this case? If so, how much? $____________. 12 . List any income -qualified stat e or federal benefits that your child(ren) receive ( POWER , Medicaid , Kid Care, Title 19 , General Assistance, Food Stamps, Supplemental Security Income, etc.): CHILD'S NAME BIRTH DATE STATE TYPE OF BENEFIT Additional sheets of paper are attached (if needed) Confidential Financial Affidavit Approved by the Wyoming Supreme Court (2012) Page 4 of 9 13. Are you currently: Employed Self -Employed Unem ployed If you are employed, please provide the following: Job No. 1: Employer’s Name: __________________________________________________________ Employer’s Address: ________________________________________________________ City, State , Zip Code: _______________________________________________________ Employer’s Phone : _________________________________________________________ Your Occupation : __________________________________________________________ Your Hourly Wage or Monthly Sa lary : _________________________________________ Job No. 2: Employer’s Name : _________________________________________________________ Employer’s Address : _______________________________________________________ City, State, Zip Code : ________________ _______________________________________ Employer’s Phone : _________________________________________________________ Your Occupation : __________________________________________________________ Your Hourly Wage or Monthly Salary : ______________________ ___________________ Job No. 3: Employer’s Na me: _________________________________________________________ Employer’s Address : _______________________________________________________ City, State, Zip Code : _____________________________________________ __________ Employer’s Phone : _________________________________________________________ Your Occupation : __________________________________________________________ Your Hourly Wage or Monthly Salary : _________________________________________ INCOME & EXPENSE INFORMATION Confidential Financial Affidavit Approved by the Wyoming Supreme Court (2012) Page 5 of 9 Add additional sheets of paper if necessary to list additional jobs. How many hours do you work each week? Job No. 1: Job No. 2: Job No. 3 Regular Regular Regular Overtime Overtime Overtime Total Total Total How often do you receive overtime compensation ? ________________________________ How often are you paid: Job No. 1: Job No. 2: Job No. 3 weekly weekly weekly every two weeks every two weeks every two weeks twice per month twice per month twice per month monthly monthly monthly annually annually annually Date of your last salary increase or decrease : _____________________________________ 14 . List all income you have receive d for the last 12 months: Income Source Monthly Amount Income Source Monthly Amount Gross Wages ** Job 1 - $ __________ Job 2 - $__________ Job 3 - $__________ Annuity $ Unemployment $ Spousal Support $ Workers’ Compensation A Contract Receipts A Socia l Security Benefits (Excluding SSI) A Rental Income A Retirement A Fringe Benefits/Bonuses A Interest/Dividend Income A Profit (Loss) from Self - Employment A Reimbursements A Other A Veterans’ Disability A Other A **Gross Wage - Monthly amou nts are calculated by multiplying weekly amount by 52 and dividing by 12; multiplying bi-weekly (every two weeks) amounts by 26 and dividing by 12; and multiplying semi -monthly (i.e., paid on the 1 st and 15th) amounts by 24 and dividing by 12. Additional sheets of paper are attached (if needed) Confidential Financial Affidavit Approved by the Wyoming Supreme Court (2012) Page 6 of 9 15. IF YOU ARE EMPLOYED : Please complete list and calculate the following: A. Gross income : $ per month (Amount of income from all sources before deductions ) B. Federal Income Tax: $____ ________ per month C. State Income Tax: $ per month D. Social Security Tax: $ per month E. Medicare Tax: $ per month F. Mandatory Retirement/Pension: $ per month G. Premium Paid for Child(ren)’s Health Insurance: $ per month H. Current Child Su pport Paid for Other Children: $ per month I. Total Mandatory Deductions : $ per month J. Net Income (line A minus line I): $ per month K. Income Tax Filing Status: L. Number of Dependents Claimed for Tax Purposes : Please provide copies of pay -stubs for all payroll deductions . Attach copies of your tax returns and W -2 forms for the most recent two years and a copy of a cumulative earning statement(s) for the current year 16. IF YOU ARE SELF -EMPLO YED : Please list the following: A. Gross income : $ per month *amount of income from all sources before deductions B. Federal Income Tax: $ per month C. State Income Tax: $ per month D. Social Security Tax: $ per month E. Medicare Tax: $ per month F. Unreimbursed Business Expenses : $ per month G. Premium Paid for Child(ren)’s Health Insurance: $ per month H. Current Child Support Paid for Other Children: $ per month I. Total Mandatory Deductions : $ per month J. Net Income (line A m inus line I): $ per month K. Income Tax Filing Status: L. Number of Dependents Claimed for Tax Purposes : Attach verified income and expense statements from your business , copies of your personal and business t ax returns , and 1099 forms for the most recent two years . Confidential Financial Affidavit Approved by the Wyoming Supreme Court (2012) Page 7 of 9 17 . List your work experience for the last three years: COMPANY AND LOCATION DATES FROM - TO JOB DESCRIPTION/ TITLE SALARY OR WAGE REASON YOU LEFT Additional sheets of paper are attached (if needed) 18. Has anyone been ordered to provide health insurance for the child(ren) involved in this case , or is there any other medical provision in an existing court order? YES NO If yes, please list who is ordered to provide insurance: Are the children currently covered by insurance? YES NO If yes, please list who is providing the insurance: If you are currently providing insurance for your children, y ou must provide current written proof from your insurance carrier verifying the names of the actual person(s) covered under your policy. Is health insurance available for the minor child(ren) through your employment? YES NO If yes, how much is the monthly premium to cover ONLY the minor child(ren) on the policy? $________________ 19 . Attach the following to this Confidential Financial Affidavit : If Employed: Copies of my las t two years income tax returns; Copies of my W -2 Forms for the last two years; and Copies of statements of earnings from each of my employers showing cumulative pay for this year. Confidential Financial Affidavit Approved by the Wyoming Supreme Court (2012) Page 8 of 9 If Self -Employed: Verified income and expense statements for the busines s for the two most recent years; and Copies of my last two years personal income tax returns. Copies of my last two years b usiness income tax returns. PERJURY STATUTE 20. Wyoming Statute § 6 -5-301 ( Perjury ) provides: (a) A person commits perjury if, while under a lawfully administered oath or affirmation, he knowingly testifies falsely or makes a false affidavit, certifica te, declaration, deposition or statement, in a judicial, legislative or administrative proceeding in which an oath or affirmation may be required by law, touching a matter material to a point in question. (b) Perjury is a felony punishable by imprisonmen t for not more than five (5) years, a fine of not more than five thousand dollars ($5,000.00), or both. OATH I have read and understand the provisions of the above perjury statute. I affirm that this Confidential Financial Affidavit (including attachme nts) contains a complete disclosure of my income from all sources and that the representations made herein concerning my income are accurate to the best of my knowledge. I am aware that the court may punish as perjury any materially false statements knowin gly made with intent to defraud or mislead. DATED this _____ day of ________________, 20_ ___. ______________________________ ________ Your Signature (Sign only in front of Notarial Officer or Court Cle rk) JURAT STATE OF _____________ ) ) ss. COUNTY OF ___________ ) Subscribed and sworn to before me on this _____ day of ________________20____, by ________________________________. WITNESS my hand and official seal. ___________________ ___________ Notarial Officer My Commissions Expires: ___________________ Confidential Financial Affidavit Approved by the Wyoming Supreme Court (2012) Page 9 of 9 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 Confidential Financial Affidavit was filed with the Clerk of District Court; and, a true and accura te copy of this 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: (P rint Respondent/Respondent ’s Attorney’s Name and Address) TO: ______________________________________ ______________________________________ ______________________________________ Your signature Print name