State of Alabama Unified Judicial System Form CS - 41 Rev CHILD - SUPPORT - OBLIGATION INCOME STATEMENT/AFFIDAVIT Case Number IN THE COUR T OF COUNTY , ALABAMA (Circ uit or District) (Name of County) Plaintiff v. Defendant AFFIDAVIT I, , being duly sworn upon my oath, state as follows : (Name of Affiant) 1. I am the P laintiff Defendant Other (please specify): in the above m atter. My Social Security number is: 2. I am are : n ot currently employed. are : Last position title: Average monthly salary in the last year of employment: $ 3. My m onthly gross income includes: ( For example of income that must be included, see back of this form. If income varies by month, enter the estimated average monthly gross income .) Employment income $ Self - employment income $ Other employment - related income $ Other non - employment - related income $ Total $ 4. I incur the following amount monthly for wo rk - related child - care : $ ( 5. The c hild(ren) of the parties is/are 6. I pay the following total amount for child support alimony in [a] prior case(s) as follows: [List case number(s) and county(ies) and state(s) here]: $ I understand that I will be required to maintain all income documentation used in preparing this Income Statement/A ffidavit (including my most recent income - t ax return ) and that such documentation shall be made available as directed by the court. I also understand that any intentional falsification of the information presented in this I ncome S tatement/ A ffidavit may subject me to the penalties of perjury. Affiant Sworn to and subscribed before me this d ay of , Notary/Clerk not covered by health from me and/or my employer. covered by health, and (1) I pay $ each month, or that amount is paid on my behalf each month by my, for the family policy coverage under which the child(ren) is/are covered; and (2) the total number of persons covered under that policy is . The pro rata portion of the attributable to the child or children who are the subjectof the support order (which shall be calculated by dividing the total actually paid by, oron behalf of, the parent ordered to provide the coverage by the total number of persons (adult and/or children) covered and then multiplying the result by the number of children who are the subject of the support order) is the sum of $ . American LegalNet, Inc. www.FormsWorkFlow.com Form CS-41 (Back) EXAMPLES OF INCOME THAT MUST BE INCLUDED IN YOUR GROSS MONTHLY INCOME Employment Income shall include, but not be limited to, salary, wages, bonuses, commissions, severanceability insurance, and SocialSecurity benefits.SelfEmployment Income shall include, but not be limited to, income from self-employment, rent, royalties,proprietorship of a business, or means gross receipts minus ordinary and necessary expenses required to produce this income.Other EmploymentRelated Income shall include, but not be limited to, the average monthly value of anyexpense reimbursements or in-kind payments received in the course of employment that are significant andreduce personal living expenses, such as a furnished automobile, a clothing allowance, and a housingallowance.Other Non-Employment-Related Income shall include, but not be limited to, dividends, interest, annuities,capital gains, gifts, prizes, and preexisting periodic alimony. RULE 32, ALABAMA RULES OF JUDICIAL ADMINISTRATION, PROVIDES THE FOLLOWING DEFINITIONS: i means the actual gross income of a parent, if the parent is employed to full capacity, or if the parent is unemployed or underemployed, then it means the actual gross income the parent has the ability to earn. Gross Income. me from any source, and includes, but is not limited to, income from salaries, wages, commissions, bonuses, dividends, severance pay, pensions, interest, trust income, annuities, capital ensation benefits, unemployment-insurancebenefits, disability-insurance benefits, gifts, prizes, and preexisting periodic alimony. ived from means-tested public-assistance programs, including, but not limited to, Temporary Assistance for Needy Families, Supplemental Security Income, food stamps, and general assistance. Selfemployment Income. For income from self-employment, rent, royalties, proprietorship of business, or joint ownership of a expenses required to produce such income, as allowed by the Internal Revenue Service, with the exceptions noted in Rule 32 (B)(3)(b). Under Internal Revenue Service for the accelerated component of depreciation expenses, investment tax credits, or any other business expenses determined by the court to be inappropriate for determining gross income for purposes of calculating child support. Other Income. Expense reimbursements or in-kind payments received by a parent in the course of employment of self-employment or operation of a business shall be counted as income if they are significant and reduce personal living expenses. American LegalNet, Inc. www.FormsWorkFlow.com