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Affidavit of Imputed Income July 2014 Page 1 of 4 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 party) AFFIDAVIT OF IMPUTED INCOME ___________________________________________________________________ (Only use this form if you are unable to get the other party to complete a Confidential Financial Affidavit. ) I, _____________________, of lawful age, first being duly sworn upon my (print name) oath, depose and state as follows: 1. I am the Petitioner OR Respondent in the above-captioned matter. 2. I am not 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. Hi s/her income for this year is unknown, as she/he has not provided financial information and has failed, neglected or otherwise refused to file a Confidential Financial Affidavit . 6. I do do not have copies of the last two year’s income tax returns showing the amount earned by Petitioner OR Respondent. ATTACH Affidavit of Imputed Income July 2014 Page 2 of 4 ANY TAX 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 vis iting the U.S. Department of Labor Bureau of Labor Statistics website for wage information by area an d occupation http://www.bls.gov/bls/blswage.htm. Attach any relevant documentation to this Affidavit. 7. Petitioner’s Respondent’s income is based on him/her being paid: ______ weekly ______ every two weeks ______ twice per month (i.e. 1 st 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 bonu ses). Monthly amounts are calculated by multiplying weekly amount by 52 and dividing by 12; multiplying bi-weekly amounts by 26 and dividing by 12; and multiplying semi-monthly amounts by 24 a nd 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 kno wledge 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 parent’s wage. Federal minimum wage is $7.25/hour as of July 1, 2012 . 8. Petitioner’s OR Respondent’s estimated gross income (before deductions) is: $_____________ per month, to the best of my information and beli ef. "Income" 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 p ermanent 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 work 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 unreimbursed 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 be considered as income . Gross income also means potential income of parents who are voluntarily unemployed or underemployed. Affidavit of Imputed Income July 2014 Page 3 of 4 "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. Paym ents towards child support arrearage shall not be deducted to arrive at net income. 9. Based on the previous work history and/or income, Petitioner OR Respondent has the ability to earn a net (after appropriate deductions) monthly income 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 mi nimum 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 . 10. Further your affiant sayeth naught. DATED this _______day of _______________, 20 _____. Signature Printed Name: Address: Phone Number: STATE OF_____________ ) ) ss. COUNTY OF___________ ) The foregoing instrument was subscribed and sworn to before me by ____________________________ this ________ day of _____________, 20 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 w as filed with the Clerk of District Court; and, a true and accurate 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: (Print Other Party/ Other Party’s Attorney’s Name and Address) TO: ______________________________________ ______________________________________ ______________________________________ Your signature Print name