Lake View School District No. 25 of Phillips County, Arkansas

Arkansas Child Support Guidelines / Affidavit of Financial Means

IN THE CHANCERY COURT OF COUNTY, ARKANSAS

Division

STATE OF ARKANSAS

COUNTY OF

AFFIDAVIT OF FINANCIAL MEANS

REVISED 01-98

THE AFFIANT, BEING DULY SWORN, SAYS UNDER PENALTY OF PERJURY THAT AFFIANT IS THE PLAINTIFF DEFENDANT PARTY (CHECK ONE) TO THIS SUPPORT ACTION HEREIN, HAS PREPARED THIS FINANCIAL STATEMENT, KNOWS THE CONTENTS THEREOF, AND THAT IT IS TRUE AND CORRECT.

INCOME

Complete item 27 on page 3

1. My weekly take-home pay (from line 27(i) on page 3)

2. I claim dependents for the purpose of determining my State of Arkansas withholding. I claim dependents for the purpose of determining my federal withholding. I did or did not (check one) claim myself as dependent. I do or do not (check one) have additional amount withheld from my payroll checks for tax purposes and, if so, that amount is per week of and itemized on reverse side. All other deductions taken from my payroll check before I receive it: total: (from line j8 on page 3).

3. I have income from the following other sources:

4. I have cash on hand in the amount of from the following source(s):

5. I have on deposit in banks and savings institutions and its source was

6. I have stocks and bonds in the amount of and their source was

CREDITORS

Complete items 28, 29 and 30 on page 4

7. Debts in the name of the plaintiff only: TOTAL UNPAID BALANCES $ TOTAL MONTHLY PAYMENTS $

8. Debts in the name of defendant only: TOTAL UNPAID BALANCES $ TOTAL MONTHLY PAYMENTS $

9. Debts in our JOINT NAMES are: TOTAL UNPAID BALANCES $ TOTAL MONTHLY PAYMENTS $

MONTHLY EXPENSES

10. My present necessary monthly expenses to support myself and child(ren) are:

(Attach schedules if needed)

TOTAL $

A check mark should be placed by all expenses which are not being paid currently.

GENERAL INFORMATION

11. My full name is

12. My social security number is Military I.D. No. (if applicable)

13. My Arkansas Driver's License Number is

14. My date of birth is . My place of birth is

15. My present resident address is

16. The full name of children born (or legally adopted) of this marriage are:

(1) Date of Birth S.S. No.

(2) Date of Birth S.S. No.

(3) Date of Birth S.S. No.

(4) Date of Birth S.S. No.

(5) Date of Birth S.S. No.

(6) Date of Birth S.S. No.

17. My employer is

18. My employer's full address is

19. My home telephone number is . My work telephone number is

INFORMATION ABOUT OPPOSING PARTY IN THIS CASE, IF KNOWN (DO NOT GUESS)

20. The opposing party's full name is

21. The opposing party's social security number is Military I.D. No. (if applicable)

22. The opposing party's Arkansas Driver's License Number is

23. The opposing party's present resident address is

24. The opposing party's employer is

25. The opposing party's employer's address

26. The opposing party's home telephone number work telephone

INCOME

27. How often are you paid, and what are your gross wages, salary or commissions due each time?

WEEKLY BIWEEKLY SEMI-MONTHLY MONTHLY OTHER

CREDITORS & DEBTS

28. Debts in the name of PLAINTIFF/Party only are:
Total Unpaid Balance(s) Monthly Payments

29. Debts in the name of DEFENDANT only are: