Fill and Sign the Following Information is True and Correct According to the Best of My Knowledge and Belief

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