IN THE CIRCUIT COURT OF _____Division _____________ Plaintiff v. _____________ Defendant COUNTY, ARKANSAS (Domestic Relations Division) Case No. _____DR__________________ AFFIDAVIT OF FINANCIAL MEANS Name:_________________________, being duly sworn, says under penalty of perjury, that he/she has prepared or approved this financial statement, and that the following information and attachments (including income verification as required by page 7) are complete, true, and correct. __________________ Date Subscribed and sworn to before me on this _____________________________ Signature day of 20 . Notary Public My commission expires: . MY INCOME 1. How often are you paid? ____ weekly ____ bi-weekly (every two weeks--26 times a year) ____ monthly ____ bi-monthly (twice a month­24 times a year) ____ other ­Explain (attach an exhibit if necessary): 2.* Net Pay: (Take-home after allowable deductions) $__________________________ *Complete worksheet on next page to determine Net Pay for calculating child support. Page 1 of 7 ______ Initials ______ Initials American LegalNet, Inc. www.FormsWorkFlow.com NET PAY WORKSHEET (If more than one employer, fill out and attach multiple copies of this worksheet). EMPLOYER: Address: Telephone #: 3. Gross Wages per pay period: $ ========= $ $ $ $ $ $ $ ALLOWABLE DEDUCTIONS UNDER STATE LAW A. Federal Income Taxes Withheld: B. State Income Taxes Withheld: C. F.I.C.A. (Social Security) or Railroad Retirement: D. Medicare: E. Health Insurance (only the portion paid for children in this case as required by page 7): F. Court-ordered child support for other children not involved in this current case. (For example, children from a previous relationship or marriage): G. TOTAL Allowable Deductions 3.H Subtract TOTAL Allowable Deductions from Gross Wages = NET PAY $ THE FINAL NUMBER IN THIS BOX BELONGS ON PAGE 1 UNDER "NET PAY" If you pay support for children not involved in this case in a form other than payroll deduction, then you should attach the child support order and proof of payment as an exhibit to this affidavit. Any other deductions from your paycheck do not figure into your net pay under Arkansas law regarding child support. Some examples of payroll deductions that you may not subtract from your income for calculating child support include: pension plans, union dues, 401(k) payments, loan repayments, charitable contributions, life insurance, and health insurance payments that cover you or your spouse. However, the court may consider these expenses, particularly if they are significant, so you should reflect them in the proper place in the pages to follow. Page 2 of 7 ______ Initials ______ Initials American LegalNet, Inc. www.FormsWorkFlow.com OTHER INCOME Other income: Bonuses or incentive pay not reflected on page 2: Other court-ordered income such as alimony/child support paid to you: Payments from a settlement or annuity: Regular gifts from relatives or friends: Investment income such as rent payments to you: Stock dividends or bond payments: Regular payments to you or on your behalf from a Trust: Other: 4 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 Amount: Source Frequency TOTAL OTHER ANNUAL INCOME: $ OTHER AVAILABLE FUNDS 5 5.1 5.2 5.3 5.4 5.5 ASSET Cash on hand, and in bank accounts: Trust fund assets held on your behalf: Stocks, bonds, mutual funds: Other (i.e. 401-K, retirement, etc): AMOUNT SOURCE TOTAL: $ Page 3 of 7 ______ Initials ______ Initials American LegalNet, Inc. www.FormsWorkFlow.com MY CURRENT MONTHLY EXPENSES * 6. a. b. Expense: Rent/house payment Gas, water, trash, & electricity Telephone Internet Media Services, i.e. Cable/Satellite, etc. Child care Amount: $ $ n. o. Expense: Health Insurance Non-covered medical (including medicine) Life insurance Car payment Car Insurance Amount: $ $ c. d. e. $ $ $ p. q. r. $ $ $ f. $ s. Car fuel and maintenance Lawn care Charitable giving Household Expenses Dry cleaning Other: Other: $ g. h. i. j. k. l. m. Food Union dues Pension plan 401(k) payments Garnishments Cigarettes Alcohol $ $ $ $ $ $ $ t. u. v. w. x. y. z. $ $ $ $ $ $ $ TOTAL: * Place a check mark by all expenses which you are not currently paying. Page 4 of 7 ______ Initials ______ Initials American LegalNet, Inc. www.FormsWorkFlow.com MINOR CHILDREN 7. a. b. c. 1. 2. 3. 4. Number of minor children I have with opposing party: Number of other minor children I have: Names of minor children involved in this case: Number of children: # # AGE CREDITORS & DEBTS 8. Debts in the names of BOTH PARTIES are: Creditor: Total amount owed: $ $ $ $ $ $ $ Totals: $ Monthly payment: $ $ $ $ $ $ $ $ a. b. c. d. e. f. g. Page 5 of 7 ______ Initials ______ Initials American LegalNet, Inc. www.FormsWorkFlow.com 9. Debts only in my name: Creditor: Total amount owed: $ $ $ $ $ Totals: $ Monthly payment: $ $ $ $ $ $ a. b. c. d. e. 10. Debts only in the name of the other party: Creditor: Total amount owed: $ $ $ $ $ Totals: $ Monthly payment: $ $ $ $ $ $ a. b. c. d. e. 11. SUMMARY OF ABOVE DEBT TABLES Summary of Debts: a. b. c. Joint Debts: My Debts: Other Party's Debts: Total Owed: $ $ $ Total Monthly Payments: $ $ $ Page 6 of 7 ______ Initials ______ Initials American LegalNet, Inc. www.FormsWorkFlow.com ACKNOWLEDGEMENT OF RESPONSIBILITIES AND CONSEQUENCES I, _________________________understand that I must comply with the following. acknowledge and agree to each provision by initialing each paragraph below. I _____Both parties must complete and exchange this seven-page affidavit by providing to opposing counsel or pro se litigants within five days before hearing. _____Both parties must supply the original notarized affidavit to the court. _____ If I am employed, I must attach copies of my last three paystubs to this affidavit. _____ If I am self-employed, I must attach copies of my last two federal and state tax returns, including all schedules, to this affidavit. _____ Before each court hearing where financial matters are at issue, I will review this document and provide updated information to the other party and to the court. _____ I understand that the cost of dependent health insurance coverage is the difference between self-only and self with dependents or family coverage or the cost of adding the child(ren) to existing coverage. _____ I understand that failing to comply with these provisions, or deliberately attempting to mislead the court or the opposing party, may result in my being held in contempt of court, being fined, being ordered to pay atto