IN THE DISTRICT COURT OF COUNTY, NEBRASKA (county where filed) , Case No. (case number assigned by lerk of ourt) Plaintiff, vs. FINANCIAL AFFIDAVIT FOR CHILD SUPPORT STATE OF NEBRASKA COUNTY OF (county where signed) I, , am under oath and I state that (first, middle and last name)the following information is true: 1. action for Choose one: [ ] There is no existing order for support for the minor childr(en) born to . OR [ ] There is currently an order for the support of the minor child(ren) of through: (name of court) (case number) (amount of support) (number of children) , ) ) ss: ) American LegalNet, Inc. www.FormsWorkFlow.com 2.I am employed at .(name of employer) My current gross monthly income is $. My income(amount of income from all sources) is based on (choose one): [ ] $ per hour for hours per week. (amount per hour) (number of hours) OR [ ] $salary per month plus monthly bonuses of (amount per month) $. (average amount per month) 3. is employed at . (name of employer) gross monthly income is $.(amount of income from all sources) This income is based on (choose one): [ ] $ per hour for hours per week. (amount per hour) (number of hours) OR [ ] $ salary per month plus monthly bonuses of (amount per month) $. (average amount per month) 4.I believe I am capable of earning more income than is currently beingearned. I base this on past employment at ,(name of employer) where my gross income per month was $, based on (amount of income from all sources) (choose one): American LegalNet, Inc. www.FormsWorkFlow.com [ ] $ per hour for hours per week. (amount per hour) (number of hours) OR [ ] $ salary per month plus monthly bonuses of (amount per month) $ (average amount of bonus) 5. I believe is capable of earning more income than is currently being earned. I base this on past employment at ,(name of employer) where gross income per month was $,(amount of income from all sources) based on (choose one): [ ] $ per hour for hours per week. (amount per hour) (number of hours) OR [ ] $ salary per month plus monthly bonuses of (amount per month) $. (average amount of bonus) 6. I dodo not ( one) have health insurance available for the child(ren)through my employment at a cost of $ per month.(cost of coverage for child(ren) only) 7. does/does not ( one) have health insurance availablefor child(ren) through employment at a cost of $ per (cost of coverage for child(en) only) month. American LegalNet, Inc. www.FormsWorkFlow.com 8. Check the boxthat applies: [ ] I contribute to a mandatory retirement plan. The minimum amount required as a contribution is $. (minimum contribution required) OR [ ] I do not contribute to a mandatory retirement plan. OR [ ] I do not have a mandatory retirement plan, but I contribute to a voluntary retirement plan. My monthly contribution is $. (average contribution) OR [ ] I do not contribute to a voluntary retirement plan. 9. Check the box that applies: []contributes to a mandatory retirement plan.Theminimum amount required as a contribution is $.(minimum contribution required)OR[]does not contribute to a mandatory retirement plan.OR[]does not have a mandatory retirement plan, butmonthly contribution is $.(averagecontribution)OR[]does not contribute to a voluntary retirement plan. American LegalNet, Inc. www.FormsWorkFlow.com 10.I have other children I am supporting.Number of children: . (number of other children) Childyears of birth: (name) (year of birth) (name) (year of birth) (name) (year of birth) For the other child(ren) I am supporting, check the box that applies: [ ] If support is court-ordered: (name of court) (case number) (amount of support) OR If support is not court-ordered: (name of other parent) (gross monthly income of other parent) 11. has other children to support. Number of children: . American LegalNet, Inc. www.FormsWorkFlow.com Childreyears of birth: (year of birth) (name) (name) (year of birth) (name) (year of birth) For the other children is supporting, check the boxthat applies: [ ] If support is court-ordered: Date Signature (Must be signed in front of a Notary Public) Full Name (Plaintiff) Full Street Address/P.O. Box City/State/ZIP Code Phone E-mail Address SUBSCRIBED AND SWORN to before me this day of , 20. Notary Public (name of court) (case number) (amount of support) OR If support is not court-ordered: (name of other parent) (gross monthly income of other parent) American LegalNet, Inc. www.FormsWorkFlow.com