Wyoming Confidential Financial Affidavit

CONFIDENTIAL FINANCIAL AFFIDAVIT

STATE OF WYOMING ) IN THE DISTRICT COURT

) ss ) __________ JUDICIAL DISTRICT

COUNTY OF )

Petitioner: Civil Action Case No.

vs.

Respondent:

PERSONAL INFORMATION

THE UNDERSIGNED, , hereby swears or affirms, 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 above):

City, State, Zip Code:

3. Your Home Phone Number: ()

Your Cell Phone Number: ()

A Message Phone Number: ()

4. Your Social Security Number:

5. Your Date of Birth:

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:

Additional sheets of paper are attached (if needed)

9. List YOUR minor children (not named above) who live with you:

Additional sheets of paper are attached (if needed)

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:

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 your child(ren) receive (POWER, Medicaid, Kid Care, Title 19, General Assistance, Food Stamps, Supplemental Security Income, etc.):

Additional sheets of paper are attached (if needed)

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 Name:

Employer's Address:

City, State, Zip Code:

Employer's Phone:

Your Occupation:

Your Hourly Wage or Monthly Salary:

Add additional sheets of paper if necessary to list additional jobs.

How many hours do you work each week?

Total Total Total

How often do you receive overtime compensation?

How often are you paid:

Date of your last salary increase or decrease:

14. List all income you have received for the last 12 months:

Additional sheets of paper are attached (if needed)

15. IF YOU ARE EMPLOYED: Please complete list and calculate 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. 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 for the most recent two years and a copy of a cumulative earning statement(s) for the current 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 your business, copies of your personal and business tax returns, and 1099 forms for the most recent two years.

17. List your work experience for the last three years:

Additional sheets of paper are attached (if needed)

18. Has anyone been ordered to provide health insurance for the child(ren) involved in this case, or is there any other medical provision in an existing court order? YES NO

If yes, please list who is ordered to provide insurance:

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 children, you must provide current written proof from your insurance carrier verifying 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.

If Self-Employed:

Verified 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 any materially false statements knowingly made with intent to defraud or mislead.

JURAT

STATE OF ) ss.

COUNTY OF )

Subscribed and sworn to before me on this day of 20, by .

WITNESS my hand and official seal.

My Commission Expires:

CERTIFICATE OF SERVICE

I certify that on (date) the original of this Confidential Financial Affidavit was 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 Respondent/Respondent’s Attorney’s Name and Address)

TO: