Fill and Sign the Financial Affidavit Form

STATE OF NORTH CAROLINA IN THE GENERAL COURT OF JUSTICE       COUNTY DISTRICT COURT DIVISION )       ) FILE NO.       Plaintiff, ) ) FINANCIAL AFFIDAVIT vs. ) )       , ) Defendant. ) I,       , who being duly sworn, deposes and says that the following information is true and correct according to the best of my knowledge and belief. ITEM 1: EMPLOYMENT AND INCOME OCCUPATION:       EMPLOYED BY:       ADDRESS:             SOC. SEC. #:       PAY PERIOD:       RATE OF PAY:       AVERAGE GROSS MONTHLY INCOME FROM EMPLOYMENT $       Bonuses, commissions, allowances, overtime, tips and similar payment $       Business income from all sources such as self-employment, partnership, close corporations, and/or independent contracts (gross receipts minus ordinary and necessary expenses required to produce income) $       Disability benefits $       Workers’ Compensation $       Unemployment Compensation $       Pensions, retirement, or annuity payments $       Social Security benefits $       Spousal support received from previous marriage $       Interest and dividends $       Rental income (gross receipts minus ordinary and necessary expenses required to produce income) $       Income from royalties, trusts, or estates $       Reimbursed expenses and in kind payments to the extent that they reduce personal living expenses $       Gains derived from dealing in property (not including nonrecurring gains) $       Itemize any other income of a recurring nature $       TOTAL MONTHLY INCOME $       LESS DEDUCTIONS Federal, state, and local income taxes (corrected for filing status and actual number of withholding allowances) $       FICA or self-employment tax (annualized) $       Mandatory union dues $       Mandatory retirement $       Health insurance payments $       Court ordered support payments for the children actually paid $       TOTAL DEDUCTIONS $       ITEM 2: AVERAGE MONTHLY EXPENSES Barber/beauty parlor       Cosmetics/toiletries       HOUSEHOLD: Gifts for special holidays       Mtg. Or rent payments       Other expenses: Property taxes & insurance                   Electricity                   Water, garbage, & sewer       Telephone       INSURANCES: Fuel oil or natural gas       Health       Repairs and maintenance       Life       Lawn and pool care       Other Insurance: Pest control                   Misc. household                   Food and grocery items       Meals outside home       OTHER EXPENSES NOT LISTED ABOVE: Other: Dry cleaning and laundry                   Affiant’s clothing                   Affiant’s medical, dental, prescriptions       AUTOMOBILE: Affiant’s beauty salon/barber       Gasoline and oil       Affiant’s gifts special holidays       Repairs       Auto tags and license       Pets: Insurance       Grooming       Other: Veterinarian                               Membership Dues: Professional dues       CHILDREN’S EXPENSES Social dues       Nursery or babysitting       School tuition       Entertainment School supplies       Vacations       Lunch money       Religious organizations       Allowance       Charities       Clothing       Medical, dental, prescriptions       Miscellaneous       Vitamins       OTHER EXPENSES:       $             $             $             $       TOTAL ABOVE EXPENSES $       PAYMENTS TO CREDITORS: TO WHOM: BALANCE DUE: MONTHLY PAYMENTS:                                                                                                                                                 TOTAL MONTHLY PAYMENTS TO CREDITORS: $       TOTAL MONTHLY EXPENSES: $       ITEM 3: ASSETS (OWNERSHIP: IF JOINT, ALLOCATE EQUALLY Description Value Husband Wife Cash (on hand or in banks) $       $       $       Stocks / bonds / notes                   Real Estate: Home:                                                                                           Automobiles:                                                                         Other personal property: Contents of home                   Jewelry                   Life ins. / cash surrender value                   Other Assets:                                                                         TOTAL ASSETS:                   ITEM 4: LIABILITIES Creditor Security Balance Husband Wife                                                                                                                                                                                                                                                                                                             TOTAL LIABILITIES $       $       $       ____________________________________ Affiant SWORN TO and signed before me on       ,       . _____________________________ NOTARY PUBLIC My Commission Expires:       CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the above Financial Affidavit has been furnished by mail this       day of       ,       , to:       . ____________________________________ Signature