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financial affidavit for child support or alimony

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					NORTH CAROLINA                                                   IN THE GENERAL COURT OF JUSTICE
COUNTY OF ________________                                          DISTRICT COURT DIVISION
                                                                    FILE NO. ____________________________

                                                                     Assigned Judge:_______________________

___________________________________,                                        FINANCIAL AFFIDAVIT OF
   Plaintiff,                                                                PLAINTIFF   DEFENDANT

v.                                                               ________________________________________
___________________________________,                             Date Completed: ____________________
   Defendant.

Employer: ______________________________ Employer telephone: ______________________________
Employer Address: _________________________________________________________________________

I am paid:          weekly,    every other week,               twice monthly,        monthly,       other _______________
  Last Taxable Year Adjusted Gross Income 1:

    Current Monthly Gross Income before Deductions:

    Current Monthly Take-home Pay after all Deductions:

    Detail of Monthly Gross Income                        Date of Separation                 Current
    Monthly Gross Wages:
    Investment income, interest, dividends:
    Bonus, commissions:
    Alimony received:
    Child Support received:
    Other (overtime, social security, disability, car
    allowance, shift pay, vacation/holiday pay):
    Mandatory Monthly Deductions                          Date of Separation                 Current
    Federal income tax:
    State income tax:
    Social Security taxes:
    Medicare taxes:
    Retirement:
    Garnishment:
    Other: _______________________________
    Voluntary Monthly Deductions                          Date of Separation                 Current
    Health Insurance:
    Dental Insurance:
    Vision Insurance:
    Life Insurance:
    Disability Insurance:
    Medical Spending Account:
    Retirement:
    Other: _______________________________



1
  This Affidavit shall be filed with the Court and a copy served on the opposing attorney/party along with copies of the required
initial disclosures.
                                             Part 1
                               Regular Recurring Monthly Expenses

Expense                              Date of Separation                   Current

                              Date: ________________________   Date: ________________________

Rent or Mortgage Payment
Renters/Homeowners
Insurance
Taxes not included in
mortgage
Routine house & appliance
repair/maintenance
Electricity

Gas, home heating fuel, oil

Water

Garbage

Cable, digital television

Telephone

Internet service

Yard maintenance

Home security system

House cleaning service

Pest control services

Automobile payment

Auto insurance

Gasoline (auto)

Auto repair/maintenance,
registration, taxes
Food and household supplies

Pets (insurance, vet, food,
kennel)
Other: _________________

GRAND TOTALS FOR
PART 1:
                                                Part 2
                                     Individual Monthly Expenses

                                     Date of Separation                  Current
                              Date: _______________________   Date: _______________________

Expense                       Self      Children   Total      Self     Children   Total

Medical Insurance premium

Dental/Vision Insurance
premium
Uninsured Medical
expenses (co-pays,
deductibles)
Uninsured Dental &
Orthodontic expense
Uninsured Prescription and
OTC drugs & medication
Other uninsured medical
expenses (e.g. optical)
Other insurance premiums
(life, disability, etc.)
Work-related child care
expense, including summer
camps
Cellular/digital mobile
telephone
Eating Out

School Lunches

Newspapers,
Magazines
Clothing, accessories

Personal Upkeep (barber,
hair stylist)
Laundry, Dry Cleaning

Education (tuition, fees,
supplies)
Babysitting, child care,
summer camp (not included
above)
Dues (professional, social,
school)
Extracurricular (piano,
sports, dance, etc.)
Church donations
                                               PART 2 CONTINUED

                                        Date of Separation                   Current
                                 Date: _______________________    Date: _______________________

Expense                          Self     Children       Total    Self     Children   Total

Other charitable
contributions
Entertainment
& Recreation
Club dues & assessments

Allowances for Children

Annual vacation

Gifts (Holidays, birthdays)

Child support for another
child
Spousal support for another
spouse
Professional fees (CPA,
etc.)
School Loans

Retirement & investment

Savings

College Fund

Other: ________________

Other: ________________

GRAND TOTALS FOR
PART 2:

                                                     Part 3
                                                     Debts

Creditor                      Balance due on      Monthly        Current        Monthly
                              DOS                 Payment        Balance due    Payment




GRAND TOTALS
FOR PART 3:
                                          VERIFICATION

        ___________________________, being first duly sworn, deposes and says that he/she is the
____________________ in the above-entitled action, that he/she has read the foregoing document
and knows the contents thereof, that the same are true of his/her own knowledge, except as to those
matters and things stated upon belief, and as to those matters and things, he/she believes them to be
true.

                                ________________________________________________________
                                   Plaintiff                Defendant

        I certify that the following person personally appeared before me this day, and           I have
personal knowledge of the identity of the principal            I have seen satisfactory evidence of the
principal’s identity, by a current state or federal identification with the principal’s photograph in the
form of a __________________________               a credible witness has sworn to the identity of the
principal; acknowledging to me that he/she voluntarily signed the foregoing document for the
purpose stated therein, and in the capacity indicated: __________________________


Date: _____________             __________________________________________________(SEAL)


                                ____________________________________________, Notary Public


(Official Seal)                 My commission expires: ____________________________________

                                   CERTIFICATE OF SERVICE

        I hereby certify that a copy of this Financial Affidavit has been served on the opposing
party/counsel in the following manner:

   By depositing a copy in the US Mail in a properly addressed, postpaid envelope to: ___________

_________________________________________________________________________________

_________________________________________________________________________________

   By hand delivery to: _____________________________________________________________

_________________________________________________________________________________

   By facsimile to: _________________________________ Fax No.: _______________________

   Other: ________________________________________________________________________

_________________________________________________________________________________


Date: _____________             ________________________________________________________
                                   Plaintiff                      Defendant
                                       SUPPORTING DOCUMENTATION

Most courts require that you provide copies of the documents which support the numbers you
included on your Financial Affidavit to the opposing party or his/her attorney. You should gather
these financial documents together and send them to the opposing party with a copy of your
Financial Affidavit. Although you must file the Financial Affidavit with the Clerk of Court, you
should NOT send copies of your supporting documents to the Court. You should bring them your
court hearing instead. Below are examples of the support documents that you might need for your
hearing:

Please provide records from                            (full calendar year preceding the date of separation) through the
present (unless indicated otherwise):

Documentary Evidence of Gross Income*:
   □        Pay Stubs
   □        Statements for all accounts in banks, credit unions, brokerage accounts and other financial institutions on
            which you have been able to sign

   □        Vouchers

   □        Direct Deposit Receipts

   □        Employee Benefit Statements

   □        Stock and Stock Option Statements
   □        W-2 forms, 1099 forms, K-1 forms and other income reporting statements

   □        Documents pertaining to health, life, casualty, automobile and liability insurance

   □        Federal and State tax returns for the past three years (individual or joint, and business interest holder)
   □        Statements for installment contracts

   □        Statements for credit card accounts

   □        Bills, statements, invoices, mortgage payment booklets or other evidence of all outstanding debts
   □        Personal financial statements furnished to any third party during the previous TWO years preceding the
            date of separation

   □        Computer generated reports or data utilizing personal accounting software programs such as Quicken or
            Microsoft Money including reports showing: incomes, expenses, profit and loss, deposits and
            withdrawals

*Gross Income means all income from whatever source derived, including but not limited to:
 Tips                                 Fees                       Commissions                        Fringe benefits

 Employment benefits                  Salaries                   Wages                              Bonuses
 Deferred Compensation                Perquisites                Severance Pay                      Capital Gains

 Interest                             Rents                      Copyrights                         Royalties

 Dividends/Distributive Shares        Alimony                    Annuities                          Pensions
 Retirement Income                    Estate Income              Trust Income                       Prizes

 Workers Compensation                 Disability Pay             Gifts                              Loans

 Social Security Benefits             Child Support (other)      Stock/Stock Options                Tax Refunds
 Income from Life Insurance           Personal Injury            Income derived from Business       Tax Credits
 and Endowment Contracts              Awards

				
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