Full Name of Party Filing Document Mailing Address (Street or Post Office Box) City, State and Zip Code Telephone Email Address (if any) IN THE DISTRICT COURT FOR THE JUDICIAL DISTRICT FOR THE STATE OF IDAHO, IN AND FOR THE COUNTY OF , Petitioner, vs. , Respondent. Case No. AFFIDAVIT VERIFYING INCOME I hereby certify that the following information is true: A. GROSS INCOME 1. Wages, salary, commissions, bonuses, etc. 2. Rent, royalties, trade, or business income, etc. (net of ordinary & necessary expenses) 3. Interest, dividends, pensions, annuities, etc. 4. Social security, worker's compensation, unemployment benefits, disability, veterans' benefits, etc. 5. Public assistance, welfare for self (not children) 6. Alimony 7. Grants, distributions from trusts, etc. 8. Other 9. SUBTOTAL FATHER MOTHER ________ ________ ________ ________ ________ ________ ________ ________ ________ AFFIDAVIT VERIFYING INCOME CAO FL 1-11 07/01/2016 PAGE 1 American LegalNet, Inc. www.FormsWorkFlow.com B. DEDUCTIONS FROM GROSS INCOME (I.C.S.G. Sections F and G) 1. Straight line depreciation on assets 2. One-half of self-employment Social Security taxes 3. Child support & alimony from another relationship 4. Support for child of another relationship living in the home 5. DEDUCTIONS SUBTOTAL C. GROSS INCOME, AS ADJUSTED (line B5 subtracted from line A9) D. IN-KIND BENEFITS (I.C.S.G. Section F(2)) (housing, food, transportation, recreation) E. POTENTIAL INCOME (I.C.S.G. Section F(3)) Potential earned income + Potential unearned income F. GUIDELINES INCOME (C + D + E) G. MONTHLY I.C.S.G. INCOME (F÷12 months) FATHER MOTHER ________ ________ ________ ________ ________ ________ ________ ________ ________ _ ________ CERTIFICATION UNDER PENALTY OF PERJURY I certify under penalty of perjury pursuant to the law of the State of Idaho that the foregoing is true and correct. Date: Typed/Printed Name Signature AFFIDAVIT VERIFYING INCOME CAO FL 1-11 07/01/2016 PAGE 2 American LegalNet, Inc. www.FormsWorkFlow.com