Fill and Sign the Returns and W 2 Forms for the Most Recent Two Years and a Copy of the Total Amount of Wages You

Confidential Financial Affidavit Approved by the Wyoming Supreme Court (2012) Page 1 of 9 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 parent) ___________________________________________________ ____________________________ CONFIDENTIAL FINANCIAL AFFIDAVIT W.S. §20 -2-308 ___________________________________________________ ____________________________ A financial affidavit must be completed by each par ent. You must attach copies of your tax returns and W-2 forms for the most recent two years and a copy of the total amount of wages you have earned so far this year. Parents who are self-employed must supply verified i ncome and expense statements from their business for the two most recent years . THE UNDERSIGNED , ___ , hereby swears or affirms, (Print Your Name) under penalty of perjury, that the following answers are correct and complete. 1. Your Name: (First, Middle, Last) ________________ ______________________________ Gender: Male Female 2. Your Present Address : ___________________________________________________ ____ City, State, Zip Code: ___________________________ ____________________________ How long have you resided at this location? _______ _______________________________ Your Mailing Address (if different from abov e) ___________________________________ City, State, Zip Code: ___________________________ ____________________________ 3. Your Home Phone Number : (___) _____________________________________________ Your Cell Phone Number : (____) ____________________________________________ __ PERSONAL INFORMATION Confidential Financial Affidavit Approved by the Wyoming Supreme Court (2012) Page 2 of 9 A Message Phone Number: ( ) 4. Your Social Security Number is: __________________ ____________________________ 5. Your Date of Birth is: 6. Your Education is: ________years of high school; _________years of college; ________ years of trade school; _______ years other (list training) 7. List your degree(s) or certificate(s): 8. List all child(ren) involved in this matter: Child’s Name Sex Birth Date Social Security No. Does this child live with you? M F Yes No M F Yes No M F Yes No M F Yes No M F Yes No Additional sheets of paper are attached (if needed) 9. List YOUR minor children (not named above) who live with you: Child’s Name Birth Date Social Security No. Additional sheets of paper are attached (if needed) Confidential Financial Affidavit Approved by the Wyoming Supreme Court (2012) Page 3 of 9 10. List YOUR minor children (not named above) who do not live with you but for whom YOU are court-ordered to pay child support: Child's Name Birth Date Social Security No. Court and Date of Order Support/Month Arrears (Amount Past Due) Child's Name Birth Date Social Security No. Court and Date of Order Support/Month Arrears (Amount Past Due) Child's Name Birth Date Social Security No. Court and Date of Order Support/Month Arrears (Amount Past Due) Child's Name Birth Date Social Security No. Court and Date of Order Support/Month Arrears (Amount Past Due) Additional sheets of paper are attached (if needed) 11 . Do you owe back child support (arrears) in this case? If so, how much? $____________. 12 . List any income-qualified state or federal benefits that you r child(ren) receive (POWER, Medicaid, Kid Care, Title 19, General Assistance, Food Stamps, Supplemental Secu rity Income, etc.): CHILD'S NAME BIRTH DATE STATE TYPE OF BENEFIT Additional sheets of paper are attached (if needed) Confidential Financial Affidavit Approved by the Wyoming Supreme Court (2012) Page 4 of 9 13. Are you currently: Employed Self-Employed Unemployed If you are employed, please provide the following: Job No. 1: Employer’s Name: __________________________________________________ ________ Employer’s Address: ___________________________________________________ _____ City, State, Zip Code: __________________________ _____________________________ Employer’s Phone : ________________________________________________ _________ Your Occupation: ________________________________ __________________________ Your Hourly Wage or Monthly Salary: _______________ __________________________ Job No. 2: Employer’s Name : ________________________________________________ _________ Employer’s Address : ________________________________________________ _______ City, State, Zip Code: __________________________ _____________________________ Employer’s Phone : ________________________________________________ _________ Your Occupation: ________________________________ __________________________ Your Hourly Wage or Monthly Salary: _______________ __________________________ Job No. 3: Employer’s Na me: ______________________________________________ ___________ Employer’s Address : ________________________________________________ _______ City, State, Zip Code: __________________________ _____________________________ Employer’s Phone : ________________________________________________ _________ Your Occupation: ________________________________ __________________________ Your Hourly Wage or Monthly Salary: _______________ __________________________ INCOME & EXPENSE INFORMATION Confidential Financial Affidavit Approved by the Wyoming Supreme Court (2012) Page 5 of 9 Add additional sheets of paper if necessary to list additional jobs. How many hours do you work each week? Job No. 1: Job No. 2: Job No. 3 Regular Regular Regular Overtime Overtime Overtime Total Total Total How often do you receive overtime compensation? _ _______________________________ How often are you paid: Job No. 1: Job No. 2: Job No. 3 weekly weekly weekly every two weeks every two weeks every two weeks twice per month twice per month twice per month monthly monthly monthly annually annually annually Date of your last salary increase or decrease: ____ _________________________________ 14 . List all income you have receive d for the last 12 months: Income Source Monthly Amount Income Source Monthly Amount Gross Wages ** Job 1 - $ __________ Job 2 - $ __________ Job 3 - $ __________ Annuity $ Unemployment $ Spousal Support $ Workers’ Compensation $ Contract Receipts $ Social Security Benefits (Excluding SSI) $ Rental Income $ Retirement $ Fringe Benefits/Bonuses $ Interest/Dividend Income $ Profit (Loss) from Self- Employment $ Reimbursements $ Other $ Veterans’ Disability $ Other $ **Gross Wage - Monthly amounts are calculated by multiplying weekly am ount by 52 and dividing by 12; multiplying bi -weekly (every two weeks) amounts by 26 and dividing by 12; and multiplying semi-monthly (i.e., paid on the 1st and 15 th ) amounts by 24 and dividing by 12. Additional sheets of paper are attached (if needed) Confidential Financial Affidavit Approved by the Wyoming Supreme Court (2012) Page 6 of 9 15. IF YOU ARE EMPLOYED: Please complete list and calculate the following: A. Gross income : $ per month (A mount of income from all sources before deductions) B. Federal Income Tax: $____________ per month C. State Income Tax: $ per month D. Social Security Tax: $ per month E. Medicare Tax: $ per month F. Mandatory Retirement/Pension: $ per month G. Premium Paid for Child(ren)’s Health Insurance: $ per month H. Current Child Support Paid for Other Children: $ per month I. Total Mandatory Deductions : $ per month J. Net Income (line A minus line I): $ per month K. Income Tax Filing Status: L. Number of Dependents Claimed for Tax Purposes: Please provide copies of pay-stubs for all payroll deductions. Attach copies of your tax returns and W-2 forms fo r the most recent two years and a copy of a cumulative earning statement(s) for the cu rrent year 16. IF YOU ARE SELF-EMPLOYED : Please list the following: A. Gross income : $ per month *amount of income from all sources before deductions B. Federal Income Tax: $ per month C. State Income Tax: $ per month D. Social Security Tax: $ per month E. Medicare Tax: $ per month F. Unreimbursed Business Expenses: $ per month G. Premium Paid for Child(ren)’s Health Insurance: $ per month H. Current Child Support Paid for Other Children: $ per month I. Total Mandatory Deductions : $ per month J. Net Income (line A minus line I): $ per month K. Income Tax Filing Status: L. Number of Dependents Claimed for Tax Purposes: Attach verified income and expense statements from y our business, copies of your personal and business tax returns , and 1099 forms for the most recent two years . Confidential Financial Affidavit Approved by the Wyoming Supreme Court (2012) Page 7 of 9 17 . List your work experience for the last three years: COMPANY AND LOCATION DATES FROM - TO JOB DESCRIPTION/ TITLE SALARY OR WAGE REASON YOU LEFT Additional sheets of paper are attached (if needed) 18. Has anyone been ordered to provide health insura nce for the child(ren) involved in this case, or is there any other medical provision in an existi ng court order? YES NO If yes, please list who is ordered to provide insu rance: Are the children currently covered by insurance? YES NO If yes, please list who is providing the insurance : If you are currently providing insurance for your ch ildren, you must provide current written proof from your insurance carrier veri fying the names of the actual person(s) covered under your policy. Is health insurance available for the minor child( ren) through your employment? YES NO If yes, how much is the monthly premium to cover ONLY the minor child(ren) on the policy? $________________ 19. Attach the following to this Confidential Financial Affidavit : If Employed: Copies of my last two years income tax returns; Copies of my W-2 Forms for the last two years; and Copies of statements of earnings from each of my employers showing cumulative pay for this year. Confidential Financial Affidavit Approved by the Wyoming Supreme Court (2012) Page 8 of 9 If Self-Employed: V erified income and expense statements for the business for the two most recent years; and Copies of my last two years personal income tax returns. Copies of my last two years business income tax returns. PERJURY STATUTE 20. Wyoming Statute § 6-5-301 (Perjury) provides: (a) A person commits perjury if, while under a lawfully administered oath or affirmation, he knowingly testifies falsely or makes a false affidavit , certificate, declaration, deposition or statement, in a judicial, legislative or administrative proceeding in which an oath or affirmation may be required by law, touching a matter material to a point in question. (b) Perjury is a felony punishable by imprisonment for not more than five (5) years, a fine of not more than five thousand dollars ($5,000.00), or both. OATH I have read and understand the provisions of the above perjury statute. I affirm that this Confidential Financial Affidavit (including attachments) contains a complete disclosure of my income from all sources and that the representations made herein concerning my income are accurate to the best of my knowledge. I am aware that the court may punish as perjury an y materially false statements knowingly made with intent to defraud or mislead. DATED this _____ day of ________________, 20____. ______________________________________ Your Signature (Si gn only in front of Notarial Officer or Court Clerk) JURAT STATE OF _____________ ) ) ss. COUNTY OF ___________ ) Subscribed and sworn to before me on this _____ day of ________________20____, by ________________________________. WITNESS my hand and official seal. ______________________________ Notarial Officer My Commissions Expires: ___________________ Confidential Financial Affidavit Approved by the Wyoming Supreme Court (2012) Page 9 of 9 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 Confidential Financial Affidavit w as filed with the Clerk of District Court; and, a true and accurate copy of th is 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: (P rint Respondent/Respondent ’s Attorney’s Name and Address) TO: ______________________________________ ______________________________________ ______________________________________ Your signature Print name