NORTH CAROLINA IN THE GENERAL COURT OF JUSTICE DISTRICT COURT DIVISION ____-CVD-__________ ___________________ COUNTY ____________________________________ ) Plaintiff ) ) vs. ) ) ____________________________________ ) Defendant ) AFFIDAVIT _______________________________________ (personnel officer), being duly sworn, deposes and says: That he/she is an employee of _____________________________________________ located in _________________________________________________________________: that _________________________________________ , in the above entitled action, is an employee of said company; that the record attached hereto of ________________________________’s earnings, deductions, company benefits and length of employment is true and correct to the best of affiant’s information and belief. This the ______ day of ___________________, 2_______. ______________________________________ Affiant (personnel officer) _______________________________________ Title Subscribed and sworn to before me this the ___________ day of ___________ , ______ . _____________________________ Notary Public My commission expires: ______________________ 1 American LegalNet, Inc. www.FormsWorkFlow.com EARNINGS INFORMAITON 1. Earnings last calendar year, including bonus, if any: a) $ __________________- b) 2. gross: net $ _________________ Present rate of pay: $ ______________ per ___________________ . If paid on production or commission, what is present average gross pay? $ ______________ per ___________ . 3. How often is employee paid? _________________________________ 4. Number of hours working per day: ___________________________ 5. Number of days working per week: __________________________ 6. Deductions from gross pay per pay period: a) State taxes: $ _______________ b) Federal taxes $ _______________ c) FICA: $ _______________ d) Medical Insurance $ _______________ * How much medical insurance premium is allocated for coverage of children? $ __________________ per ______________________ . 7. Number of exemptions claimed: __________________ 8. Date employee last paid: ____________________ How many pay periods, if any, are employee’s earnings retained by employer? ________________________ . 9. Earnings this calendar year through date employee last paid, including bonus, if any? a) $ ____________ b) 10. gross net $ ____________ Is employee paid a bonus: ___________________If “yes,” please explain: a) How computed: ________________________________ b) When paid: ______________________________ c) Amount paid last calendar year: _____________________________ d) Amount paid this calendar year: _____________________________ 2 American LegalNet, Inc. www.FormsWorkFlow.com 11. What pay increase, if any, has employee received in past twelve (12) months? Increase amount(s): ______________________________________________ Date(s) received: ________________________________________________ 12. Nature of employment: ________________________________________________ 13. Date of hire: _____________________________ 14. Amount paid by employer on employee’s benefit for: a) Medical insurance $ ______________ per ________________ . b) Disability insurance: $ ______________ per ________________ . c) Dues: $ ______________ per ________________ . d) Retirement: $ ______________ per ________________ . e) Reimbursed Expenses: $ ______________ per ________________ . 15. Amount of overtime employee worked in the past twelve (12) months. ___________________________________________________________________ __________________________________________________________________ . 16. Amount of overtime that was available to employee in the past twelve (12) months. ____________________________________________________________________ ____________________________________________________________________ . 17. Please describe changes employee should expect, if any, within three months in job description, compensation and/or working hours: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ___________________________________________________________________ . 18. If not previously described herein, please describe changes, if any, employee has had within past three months in job description, compensation and/or working hours: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ___________________________________________________________________ . 3 American LegalNet, Inc. www.FormsWorkFlow.com