Preparing a Financial Affidavit

Financial Affidavit

INSTRUCTIONS: This affidavit will help you present detailed information for use in determining the correct amount of child support to be ordered based on the North Dakota Child Support Guidelines (N.D. Admin. Code ch. 75-02-04.1). Please complete this form and sign it in front of a Notary Public. If you need more space, please attach additional pages. Additional information can also be provided in the Comment section at the end.

Completing this form fully and accurately will allow you to present information that the court will use to determine your ability to pay child support under the guidelines.

Attach all requested documents and additional pages and return to the Regional Child Support Unit at

1. PERSONAL BACKGROUND

Name: Last four digits of SSN:

Year of birth:

Education (list degrees held):

List the names and dates of birth of your biological or adopted children who do not live with you and the name of the person with whom each child lives, along with that person’s relationship to the child:

Child’s name       Date of birth       Lives with (name/relationship)

List the names and dates of birth of your biological or adopted children who live with you:

Child’s name       Date of birth

If you have an adopted child, is the adoption subsidized? Yes No

If yes, name of the individual receiving the subsidy payment: and the state providing the payment:

Are you currently incarcerated?

Yes No

If yes, name and address of prison, jail, or correctional facility where you are confined:

Prisoner Identification Number:

Date that your current period of incarceration began:

Maximum release date:

Are you on work release? Yes No

If yes, date that work release began:

Have you been released from incarceration within the past six months? Yes No

If yes, date of release:

Are you currently under any medical restrictions that limit your ability to work? Yes No

If yes, describe the restrictions:

2. TAX EXEMPTIONS FOR CHILDREN AND CHILD TAX CREDIT

List all the children you claim as exemptions on your federal income tax return. If any of these children are not your biological or adopted children, please indicate the relationship.

Child’s name       Relationship

Do you claim the exemption for any of your biological or adopted children based on a court order? Yes No

If yes, please list the names of the children for whom the exemption is claimed based on the court order:

Do you alternate claiming the exemption for any of your biological or adopted children with the other parent based on a court order? Yes No

If yes, please list the names of the children for whom the exemption is alternated based on the court order:

Are any of your biological or adopted children for whom you claim an exemption qualifying children for purposes of the child tax credit? Yes No

If yes, please list the names of the children who are qualifying children for purposes of the child tax credit:

3. PRIMARY RESIDENTIAL RESPONSIBILITY (CUSTODY)

Do you and the other parent in this child support matter have split primary residential responsibility for your children? Yes No

Do you and the other parent in this child support matter have equal residential responsibility for your child or, if there are multiple children, for any or all of those children? Yes No

4. PARENTING TIME (VISITATION)

Does a court order specify when you have parenting time with your children? Yes No

If yes, based on the court order, is the number of nights any of your children spend with you more than 60 of 90 consecutive nights? Yes No

More than an annual total of 164 nights? Yes No

If you answered yes to either of the last two questions, please provide the total number of court-ordered parenting time nights per child, per year:

Child’s name       Total number of court-ordered parenting time nights per year

5. CHILDREN'S BENEFITS

Do the children in this child support matter receive any governmental or other benefits on your account? Yes No

If yes, list the names of the children, the type of benefit they are receiving, and the monthly amount of such benefit:

Child’s name       Type of benefit       Monthly amount

6. EMPLOYMENT

If you are employed, you must attach:

• A copy of your most recent federal income tax return, including copies of all W-2s, 1099s, and schedules.

• A copy of a year-end or final pay stub from each employer who gave you a W-2 form to attach to your most recent federal income tax return.

• For the current year, copies of your most recent pay stubs from all employers to show your year-to-date income from each employer (this includes your leave and earnings statement, if you are in the military).

Note: If you have more than one employer, please answer the questions in this section based on your primary job. Then attach additional pages to provide the same kind of information for each of your other jobs.

Employer name:

Employer address:

Employer telephone number:

Date you started working for this employer:

Occupation:

Brief job description:

Rate of pay (complete the option that best describes your situation)

Hourly: $ per hour; hours per week

Monthly: $ per month

Annually: $ per year

Number of pay periods (check one)

weekly

24 per year (paid twice per month)

26 per year (paid every two weeks)

monthly

other

Overtime

Did you work any overtime hours during the past 24 months? Yes No

If yes, provide the number of overtime (OT) hours worked in each of the past 24 months:

OT hours    OT hours

OT hours    OT hours

Rate of pay for overtime hours: $

Do you expect to continue to have overtime hours during the next 12 months? Yes No; because

Commissions and tips

Commissions: $ per

Tips: $ per

Bonuses

Did you receive any bonuses during the past three (3) calendar years? Yes No

If yes, provide the amount of bonuses received in each of the past three (3) calendar years and the reason for the bonuses:

Year Amount $ Reason:

Year Amount $ Reason:

Year Amount $ Reason:

Do you expect to receive a bonus during the current calendar year? Yes No; because:

Employee benefits

Describe the benefits provided to you by your employer and the annual value of each benefit:

Benefit provided       Annual value

In-kind income

Describe any in-kind income provided to you by your employer and the annual value of the in-kind income.

In-kind income received       Annual value

Union dues: $ per month Name of union:

Are union dues required as a condition of employment? Yes No

List each professional/occupational license you hold:

Is the license required as a condition of employment? Yes No

Annual professional/occupational license fee: $

Is this fee paid or reimbursed by your employer? Yes No

Are you required, as a condition of employment, to contribute to a retirement plan? Yes No

If yes, monthly amount of required contribution: $

Employee expenses

Do you have out-of-pocket expenses for special equipment or clothing required as a condition of your employment? Yes No

If yes, describe these items, your annual out-of-pocket expenses for them, and the amount, if any, that you are reimbursed for them:

Item       Annual out-of-pocket expenses       Amount reimbursed

Do you have out-of-pocket expenses for lodging when you must travel as a condition of your employment? Yes No

If yes, are you reimbursed for these lodging expenses? Yes No

If no, please provide the number of overnights in the last calendar year: and the current calendar year to date:

Are you required, as a condition of employment, to use your personal vehicle to drive between work locations? Yes No

If yes, are you reimbursed for these mileage expenses? Yes No

If no, please provide the number of these miles driven in the last calendar year: and the current calendar year to date:

Military Service

Are you currently in the military? Yes No

If yes, branch of service:

Rank:

Years of service:

Duty station (base and state or foreign country):

List any monthly payments and allowances that have not already been included above:

Type of payment or allowance       Monthly amount

7. HEALTH INSURANCE AND MEDICAL EXPENSES

Do you have access to health insurance coverage, including dental or vision coverage, for your children? Yes No

Are you currently enrolled in the health insurance plan? Yes No

If yes, indicate what type of plan you are currently enrolled in:

Single

Single + dependent

Family

If you are currently enrolled in the plan, please provide the names of persons, including yourself, covered under the plan and the effective date of the coverage:

Name of insured       Effective date

Name of insurance company:

Address of insurance company:

Telephone number of insurance company:

Group number:

Policy number:

Name of policyholder:

If you are not currently eligible for coverage, on what date will you become eligible?

Your cost for health insurance is/would be:

Single plan: $ per

Single + dependent plan: $ per

Family plan: $ per

Child-only plan: $ per

Do you currently have dental insurance for your children? Yes No

Name of insurance company:

Group number:

Policy number:

Cost of coverage:

Name of insured       Effective date

Your cost for dental insurance is/would be:

Single plan: $ per

Single + dependent plan: $ per

Family plan: $ per

Child-only plan: $ per

Do you currently have vision insurance for your children? Yes No

Name of insurance company:

Group number:

Policy number:

Cost of coverage:

Name of insured       Effective date

Your cost for vision insurance is/would be:

Single plan: $ per

Single + dependent plan: $ per

Family plan: $ per

Child-only plan: $ per

Annual amount of out-of-pocket medical expenses you pay for the children for whom support is being determined in this child support matter:

Child’s name       Annual amount

$

$

$

$

Is it reasonably likely that these medical expenses will continue? Yes No

If yes, please explain what these expenses are for:

8. UNEMPLOYMENT INFORMATION

If you are currently unemployed, please provide the following information about your last employment.

Reason for unemployment:

Date you became unemployed:

Name and address of last employer:

Occupation:

Brief job description for your last employment:

Wages for last employment

Hourly: $ per hour; hours per week

Monthly: $ per month

Annually: $ per year

Number of pay periods for last employment:

weekly

24 per year (paid twice per month)

26 per year (paid every two weeks)

monthly

other

Overtime

Average number of overtime hours worked per month during the final 36 months of your last employment:

Rate of pay for overtime hours: $

Commissions: $ per

Tips: $ per

Did you receive severance pay when you became unemployed? Yes No

If yes, amount received: $

Are you now receiving or, within the past 36 months, did you receive unemployment compensation? Yes No

If yes, weekly compensation amount: $

Date unemployment compensation began:

Date unemployment compensation ended/will end:

Work history

Describe other jobs you have had in the past, aside from your last employer:

9. SELF-EMPLOYMENT INCOME

Structure of business entity:

Sole proprietorship

Partnership; percent ownership interest:

Limited liability company; percent ownership interest:

S Corporation; percent ownership interest:

C Corporation; percent ownership interest:

Name of business entity:

Business address:

Business telephone number:

Taxpayer identification number(s):

Type of business:

Farming/ranching

Service

Retail sales

Wholesale sales

Manufacturing

Other; please describe:

Description of business activity:

How long has this business been in existence? years months

Names of household members who work in this business, the wage/salary paid to the household member, and household member’s job duties:

Household member’s name       Wage/salary       Job duties

10. OTHER INCOME

If you are receiving worker’s compensation, social security payments, veterans’ benefits, military retirement payments, railroad retirement board payments, or any other disability or retirement payments, please attach a copy of your benefits award letter or other documentation showing the amount received.

Are you now receiving worker’s compensation wage replacement payments? Yes No

If yes, weekly payment amount: $

Date payments began:

Date payments ended/will end:

Are you receiving social security disability payments? Yes No

If yes, monthly payment amount: $

Date payments began:

Are you receiving social security retirement payments? Yes No

If yes, monthly payment amount: $

Date payments began:

Are you receiving social security survivor’s payments? Yes No

If yes, monthly payment amount: $

Date payments began:

Are you receiving SSI payments? Yes No

Are you receiving veterans’ pension or disability benefits? Yes No

If yes, monthly payment amount: $

Date payments began:

If disability benefits, percent disabled:

Are you receiving military retirement payments? Yes No

If yes, monthly payment amount: $

Date payments began:

Are you receiving total and permanent disability payments from the railroad retirement board? Yes No

If yes, monthly payment amount: $

Date payments began:

Are you receiving occupational disability payments from the railroad retirement board? Yes No

If yes, monthly payment amount: $

Date payments began:

Are you receiving retirement payments from the railroad retirement board? Yes No

If yes, monthly payment amount: $

Date payments began:

Are you receiving any other disability, retirement, or pension payments not included above? Yes No

If yes, source of payments:

Monthly payment amount: $

Date payments began:

Dividends and interest: $ per

Annuities income: $ per

Trust income: $ per

Currently deferred income: $ per

Receipt of previously deferred income: $ per

Was this treated as income to you at the time it was deferred? Yes; amount previously counted: $ No

Gifts and prizes (exceeding $1,000/year): $ per

Refundable tax credits: $

Gains: $

Describe transaction resulting in gains:

Spousal support (alimony) payments received: $ per

Rental income: $ per

Mineral lease income: $ per

Income from royalties: $ per

Other (specify) : $ per

11. COMMENTS

Please use this section to provide any other information that you feel would help the Regional Child Support Unit to understand your situation or to supplement answers given above, including any factors that affect your ability to work:

12. CHECKLIST OF ATTACHED DOCUMENTS

Please put a check mark next to the documents that are attached to this form:

Business and personal federal income tax returns for the last five years (if self-employed).

Business profit and loss statements for the last five years (if self-employed).

Most recent federal income tax return, including W-2s, 1099s, and schedules.

Year-end or final paystub from each employer who gave you a W-2 form.

Year-to-date paystub from each employer for the current year.

Leave and earnings statement for the current year (if in the military).

Unemployment compensation benefits award letter.

Worker’s compensation benefits award letter.

Social security benefits award letter (for disability, retirement, or survivor’s payments).

SSI benefits award letter.

Veterans’ pension or disability benefits award letter.

Military retirement award letter.

Railroad retirement board benefits award letter.

Proof of expenses for employment-related special equipment, clothing, lodging, or mileage for driving between work locations.

Proof of out-of-pocket medical expenses paid for the children for whom support is being determined in this child support matter.

Current medical records confirming any work restrictions.

13. SIGNATURE

I state, under penalty of perjury, that the information contained in, and attached to, this Financial Affidavit, is true and correct to the best of my knowledge.

Subscribed and sworn to before me this day of , .