Appendix E IN THE DISTRICT COURT OF DOUGLAS COUNTY, KANSAS In the Matter of: ) ) ____________________________________ ) Petitioner, ) and ) ____________________________________ ) Respondent. ) _________________________________________ ) Case No. DG_________ Division ___ POST-DECREE DOMESTIC RELATIONS AFFIDAVIT OF ___________________________________________________ (Your name) To be used with post-decree Motions to Establish or Modify Child Support ONLY. 1. Your Name: ________________________________________________________________________ First Middle Last Residence: ________________________________________________________________________ Street Address City State Zip ___________________ ______________________ XXX-XX_____________ Home phone number Work phone number Social Security Number Year of Birth 2. Please provide information on minor children of the relationship in this case for whom child support is being calculated. Name Social Security Number Year of Birth/Age Resides With _____________________ XXX-XX__________/____ ___________________ _____________________ XXX-XX__________/____ ___________________ _____________________ XXX-XX__________/____ ___________________ _____________________ XXX-XX__________/____ ___________________ 3. Please provide information on minor children of previous relationships and facts as to custody and support payments paid or received, if any. Name Resides With Year of Birth Support Paid/Rec’d Case No/County __________________ ______________ ____________ ________________ _____________ __________________ ______________ ____________ ________________ _____________ __________________ ______________ ____________ ________________ _____________ __________________ ______________ ____________ ________________ _____________ 4. Please provide information on minor children of current relationship that are living with you. (Please include biological/adopted children only.) Name Year of Birth ___________________________ _______________ ___________________________ _______________ ___________________________ _______________ ___________________________ _______________ American LegalNet, Inc. www.FormsWorkFlow.com 5. You are employed by: Name: Address: 6. Income for Wage Earner:: A. Gross earnings per pay period __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ $___________________ How often?___ ____________ (weekly, every two weeks, twice per month, monthly) B. Other Income received $___________________ How often?________________ (weekly, every two weeks, twice per month, monthly) 7. Monthly income for Self-Employed A. Gross Income B. Other income received C. Reasonable Business Expenses (Itemize on attached exhibit) D. Self-Employment Tax E. Estimated Tax Payments $___________________ $___________________ $___________________ $___________________ $___________________ 8. Are you receiving Unemployment Compensation? Yes/No Weekly amount: $ ________________ For how many weeks are you eligible? __________________ 9. Are you receiving Social Security Supplemental Income or Social Security Disability benefits? Yes/No If yes, $________________ per month What date did you start receiving it? _____________ 10. Work-Related Child Care Expenses for child(ren) for whom support is being calculated: (You must attach proof of payment such as canceled checks, receipts, child care tax credit schedule, printouts or letter from child care provider.) A. Name and Address of Provider _______________________________________________ _______________________________________________ _______________________________________________ B. 11. Weekly Summer Expense $____________________ Weekly School Year Expense $_____________________ Name and Address of Provider _______________________________________________ _______________________________________________ _______________________________________________ Who provides health insurance for child(ren)? ______ Father ______ Mother _____ Other A. Name and address of health insurance plan: ___________________________________________ ___________________________________________ ___________________________________________ B. Persons insured on plan: _________________________________________________________ _________________________________________________________ C. Monthly cost of employee only coverage for: health insurance $ __________________ dental insurance $ __________________ vision insurance $ __________________ drug prescription insurance $ __________________ American LegalNet, Inc. www.FormsWorkFlow.com D. E. 12. Monthly cost insured is currently paying for (including costs to add dependents): health insurance $ __________________ dental insurance $ __________________ vision insurance $ __________________ drug prescription insurance $ __________________ If your employer provides a benefit allowance and you choose a plan which equals, exceeds, or is less than that allowance, please provide amount of allowance and your additional contribution, if any. Also, if your employer pays for you declining insurance or choosing a less expensive plan, please provide the monthly amount you receive: _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ Who claims child(ren) for income tax purposes? _____ Father _____ Mother OR You file taxes as: _____ Single _____ Alternate/Share exemptions _____ Head of Household _____ Joint _____ Other 13. Child Support Adjustments requested: (If no adjustment is requested, do not complete this section. The requesting party must prove the basis for the adjustments. Documentation to support requested adjustments must be attached.) _____ Long Distance Parenting Time Adjustment (+/-) $______________ _____ Parenting Time Adjustment (+/-) $______________ _____ Income Tax Adjustment (if not sharing or alternating exemption(s)) (+/-) $______________ _____ Special Needs/Extraordinary Expenses (+/-) $______________ _____ Agreement Past Minority (when parent having primary residency seeks increase for child(ren) under 18) (+/-) $______________ _____ Overall Financial Condition (+/-) $______________ 14. The following documents must be attached. Social Security numbers and dates of birth must be removed from the documents prior to filing with the court. _____ Current pay stub _____ Last year's Federal Income Tax Return including schedules _____ W-2 (if tax return not yet completed) _____ Written proof of work-related child care costs _____ Written proof of insurance costs _____ Other (statement regarding requested child support adjustment(s)) I declare under penalty of perjury under the laws of the state of Kansas that the foregoing is true, correct and complete. Executed on the _____ day of _______________________________________, 20_____. ___________________________________________ Your name (Print): ___________________________ American LegalNet, Inc. www.FormsWorkFlow.com