Fill and Sign the Preparing a Financial Affidavitthe Gufford Law Firm Pa Form

Financial Affidavit/Page 1 of 15/January 2018 FINANCIAL AFFIDAVIT INSTRUCTIONS: This affidavit will help you present detailed info rmation 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 c h. 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 ca n also be provided in the Comment section at the end. Completing this form fully and accurately will allo w you to present information that the court will use to determine your ability to pay chi ld 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 digit s of SSN: _______________ Year of birth: ________________________ Education (list degrees held): ____________________ ____________________________ ___________________________________________________ ____________________ List the names and dates of birth of your biologica l 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/relatio nship) ______________________ _____________ ______________ __________ ______________________ _____________ ______________ __________ ______________________ _____________ ______________ __________ ______________________ _____________ _________ _______________ List the names and dates of birth of your biologica l or adopted children who live with you: Child’s name Date of birth ______________________________ __________________ ______________________________ __________________ ______________________________ __________________ ______________________________ __________________ If you have an adopted child, is the adoption subsi dized? _____ Yes _____ No If yes, name of the individual receiving the subsid y payment (if you receive the payment, enter your name or if another individual r eceives the payment, enter his or her name): ____________________________ and the st ate (North Dakota or another state) providing the payment: ____________ _______ Financial Affidavit/Page 2 of 15/January 2018 Are you currently incarcerated (physically confined to a prison, jail, or other correctional facility)? _____ Yes _____ No If yes, name and address of prison, jail, or correc tional facility where you are confined: ________________________________________ _______________ ________________________________________ ________________________ __________________________________________________ ______________ Prisoner Identification Number: ___________ Date that your current period of incarceration bega n (do not include any time that you were confined while awaiting trial or sentencin g): _____________ Maximum release date: _________________ Are you on work release? _____ Yes _____ No If yes, date that work release began: __________ _ (Provide the details of your work release employmen t in Section 6. Do not skip Sections 2 through 5.) Have you been released from incarceration within th e past six months? _____ Yes _____ No If yes, date of release: _____________________ Are you currently under any medical restrictions that limit your abi lity to work? _____ Yes _____ No If yes, describe the restrictions: ______________ ________________ __________________________________________________ _____ Note: You must attach copies of medical records th at confirm the work restrictions if you want them to be considered. 2. TAX EXEMPTIONS FOR CHILDREN AND CHILD TAX CREDIT List all the children you claim as exemptions on yo ur federal income tax return. If any of these children are not your biological or adopted c hildren, please indicate the relationship (for example, stepchild). Child’s name Relationship _________________________________ ________________ _________________________________ ________________ _________________________________ ________________ _________________________________ ________________ Financial Affidavit/Page 3 of 15/January 2018 Do you claim the exemption for any of your biologic al or adopted children based on a court order? _____ Yes _____ No If yes, please list the names of the children for w hom 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 of those children based on a court order? _____ Yes _____ No If yes, please list the names of the children for w hom 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 c redit? _____ Yes _____ No If yes, please list the names of the children who a re qualifying children for purposes of the child tax credit: __________________________________________ __________________________________________ __________________________________________ __________________________________________ 3. PRIMARY RESIDENTIAL RESPONSIBILITY (CUSTODY) Do you and the other parent in this child support m atter have split primary residential responsibility for your children? (Split primary r esidential responsibility means that you and the other parent have more than one child in co mmon and you and the other parent each have primary residential responsibility for at least one child.) _____ Yes _____ No Do you and the other parent in this child support m atter have equal residential responsibility for your child or, if there are mult iple children, for any or all of those children? (Equal residential responsibility means each parent, by court order, has residential responsibility for the child or childre n for an equal amount of time.) _____ Yes _____ No Financial Affidavit/Page 4 of 15/January 2018 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? _____ Ye s _____ No If you answered yes to either of the last two quest ions, please provide the total number of court-ordered parenting time nights per c hild, per year: Child’s name Total number of court-ordered parentin g time nights per year _____________________ __________ _____________________ __________ _____________________ __________ 5. CHILDREN’S BENEFITS Do the children in this child support matter receiv e any governmental or other benefits on your account? (Examples include dependent’s ben efits from the Social Security Administration based on your disability or retireme nt.) _____ 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 retur n, including copies of all W-2s, 1099s, and schedules. • A copy of a year-end or final pay stub from each em ployer who gave you a W-2 form to attach to your most recent federal income t ax return. • For the current year, copies of your most recent pa y 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 mil itary). Note: If you have more than one employer, please a nswer the questions in this section based on your primary job. Then attach add itional pages to provide the same kind of information for each of your other job s. Employer name: ________________________________ Employer address: ______________________________ ______________________________________________ Financial Affidavit/Page 5 of 15/January 2018 Employer telephone number: _______________________ ____ Date you started working for this employer: _______ __________ Occupation: _______________________________________ ___ Brief job description: ___________________________ _______________________ Rate of pay (complete the option that best describe s your situation) Hourly: $________ per hour; ________ hours per wee k 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 w orked in each of the past 24 months: mo/yr ______ OT hours _____ mo/yr ________ OT hou rs _____ mo/yr ______ OT hours _____ mo/yr ________ OT hou rs _____ mo/yr ______ OT hours _____ mo/yr ________ OT hou rs _____ mo/yr ______ OT hours _____ mo/yr ________ OT hou rs _____ mo/yr ______ OT hours _____ mo/yr ________ OT hou rs _____ mo/yr ______ OT hours _____ mo/yr ________ OT hou rs _____ mo/yr ______ OT hours _____ mo/yr ________ OT hou rs _____ mo/yr ______ OT hours _____ mo/yr ________ OT hou rs _____ mo/yr ______ OT hours _____ mo/yr ________ OT hou rs _____ mo/yr ______ OT hours _____ mo/yr ________ OT hou rs _____ mo/yr ______ OT hours _____ mo/yr ________ OT hou rs _____ mo/yr ______ OT hours _____ mo/yr ________ OT hou rs _____ Rate of pay for overtime hours: $________ Do you expect to continue to have overtime hours du ring the next 12 months? _____ Yes _____ No; because ____________________ _________ Commissions and tips Commissions: $________ per __________ Tips: $________ per __________ Financial Affidavit/Page 6 of 15/January 2018 Bonuses Did you receive any bonuses during the past three ( 3) calendar years? _____ Yes _____ No If yes, provide the amount of bonuses received in e ach 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 emplo yer and the annual value of each benefit (examples include accrued vacation and sick leave, health insurance, employer retirement contributions, etc.) : 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 means you are allowed to use your employer’s property or you are being provided with services at no charge or less than the usual charge. Examples include housing all owance or the use of living quarters or being provided with transportation, gro ceries, or utilities.) In-kind income received Annual value _________________________________________ ______ ____ _________________________________________ ______ ____ _________________________________________ ______ ____ Union dues: $________ per month Name of union: ________________________ Are union dues required as a condition of employme nt? _____ Yes _____ No (If yes, you must provide proof from your employer if you want this expense to be considered.) List each professional/occupational license you hol d:___________________________ Is the license required as a condition of employme nt? _____ Yes _____ No Annual professional/occupational license fee: $__ _____ Is this fee paid or reimbursed by your employer? _____ Yes _____ No Financial Affidavit/Page 7 of 15/January 2018 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 equi pment or clothing required as a condition of your employment? _____ Yes _____ No If yes, describe these items, your annual out-of-po cket expenses for them, and the amount, if any, that you are reimbursed for the m: Item Annual out-of-pocket expenses Amount reimbu rsed ___________________ _________________________ _______________ ___________________ _________________________ _____ __________ ___________________ _________________________ _____ __________ 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 expens es? _____ Yes _____ No If no, please provide the number of overnights in t he 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 (this does not include driving between your home and your work)? _____ Yes _____ No If yes, are you reimbursed for these mileage expen ses? _____ Yes _____ No If no, please provide the number of these miles dr iven in the last calendar year: ____________ and the current calendar year t o date: _________ Note: If you claim any employment-related expenses for special equipment, clothing, lodging, or mileage, you must provide proof of those expenses if you want them to be considered. 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): ________________________ ________________________ Financial Affidavit/Page 8 of 15/January 2018 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, in cluding dental or vision coverage, for your children? _____ Yes _____ No If coverage is or would be available, please provid e the following information: Are you currently enrolled in the health insurance plan? _____ Yes _____ No If yes, indicate what type of plan you are current ly enrolled in: _____ Single _____ Single + dependent _____ Family If you are currently enrolled in the plan, please p rovide 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 (if multiple numbers, please provide the “member services” number): ____________ ___________ Group number: ________________ Policy number: ________________ Name of policyholder: ______________ If you are not currently eligible for coverage, on what date will you become eligible? _______________________ Financial Affidavit/Page 9 of 15/January 2018 Your cost for health insurance is/would be (complet e all options that are/would be available): 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 If yes: Name of insurance company: _______________________ _____ Group number: ___________________________________ ____ Policy number:____________________________________ ____ Cost of coverage: _______________________________ ______ Name of insured Effective date ______________________________ ____________ ______________________________ ____________ ______________________________ ____________ Your cost for dental insurance is/would be (complet e all options that are/would be available): 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 If yes: Name of insurance company: _______________________ _____ Group number:_____________________________________ ___ Policy number:____________________________________ ____ Cost of coverage: _______________________________ ______ Name of insured Effective date ______________________________ ____________ ______________________________ ____________ ______________________________ ____________ Your cost for vision insurance is/would be (complet e all options that are/would be available): Single plan: $_______ per ________ Single + dependent plan: $________ per ________ Family plan: $_______ per ________ Child-only plan: $_________ per _________ Financial Affidavit/Page 10 of 15/January 2018 Annual amount of out-of-pocket medical expenses you pay for the children for whom support is being determined in this child support m atter: 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: _______________________ __________________________________________________ ______________ Note: You must provide proof of these expenses if you want them to be considered. 8. UNEMPLOYMENT INFORMATION If you are currently unemployed, please provide the following information about your last employment. Also, you must attach: • A copy of your most recent federal income tax retur n, including all W-2s, 1099s, and schedules. • A copy of your final pay stub from your last employ er. • If you are receiving or have received unemployment compensation, a copy of your benefits award letter or other documentation s howing the amount received. 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 wee k Monthly: $________ per month Annually: $________ per year Financial Affidavit/Page 11 of 15/January 2018 Number of pay periods for last employment (check on e) _____ 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 d uring the final 36 months of your last employment: ________ Rate of pay for overtime hours: $________ Commissions and tips for last employment Commissions: $________ per __________ Tips: $________ per __________ Bonuses Please provide information regarding the amount of and reason for any bonuses you received during the final 36 months of your las t employment: __________ ___________________________________________________ ____________ ___________________________________________________ ____________ Did you receive severance pay when you became unemp loyed? _____ 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, asid e from your last employer: ___________________________________________________ ____________ __________________________________________________ _____________ __________________________________________________ _____________ 9. SELF-EMPLOYMENT INCOME If you are self-employed, you must attach: • Copies of your personal and business federal income tax returns, including all schedules, for the last five years. These include, as applicable, IRS forms 1040, 1065, 1120, and 1120S. • If you do not have income tax returns, copies of pr ofit and loss statements for the last five years. Financial Affidavit/Page 12 of 15/January 2018 Note: If you have more than one self-employment ac tivity, please answer the questions in this section based on your primary sel f-employment activity. Then attach additional pages to provide the same kind of information for each of your other self-employment activities. 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 (e.g., type of ser vice provided, type of item(s) sold, etc.): ___________________________________________________ __________________ ___________________________________________________ __________________ How long has this business been in existence? ____ _ years _____ months Names of household members who work in this busines s, 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 amo unt received. Financial Affidavit/Page 13 of 15/January 2018 Are you now receiving or did you receive worker’s c ompensation wage replacement payments? _____ Yes _____ No If yes, weekly payment amount: $_____________ Date payments began: ________________ Date payments ended/will end: __________ Are you receiving social security disability paymen ts (this does not mean Supplemental Security Income (SSI))? _____ Yes _____ No If yes, monthly payment amount: $________ Date payments began: ____________ Are you receiving social security retirement paymen ts? _____ Yes _____ No If yes, monthly payment amount: $__________ Date payments began: ______________ Are you receiving social security survivor’s paymen ts? _____ Yes _____ No If yes, monthly payment amount: $__________ Date payments began: ______________ Are you receiving SSI payments? (Note: SSI paymen ts are not treated as income under the guidelines.) _____ Yes _____ No Are you receiving veterans’ pension or disability b enefits? _____ 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 pa yments from the railroad retirement board? _____ Yes _____ No Financial Affidavit/Page 14 of 15/January 2018 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 rail road 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 __________ Financial Affidavit/Page 15 of 15/January 2018 11. COMMENTS Please use this section to provide any other inform ation that you feel would help the Regional Child Support Unit to understand your situ ation 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 ret urns 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, inclu ding 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 let ter. _____ Worker’s compensation benefits award letter. _____ Social security benefits award letter (for d isability, retirement, or survivor’s payments). _____ SSI benefits award letter. _____ Veterans’ pension or disability benefits awa rd letter. _____ Military retirement award letter. _____ Railroad retirement board benefits award let ter. _____ Proof of expenses for employment-related spe cial 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 informa tion contained in, and attached to, this Financial Affidavit, is true and correct to the bes t of my knowledge. Date: _______________ Signature: ________________ ____________ Subscribed and sworn to before me this _____ day of ______________, ______. ________________________________ Notary Public _____________ County, North Dakota