STATE OF NORTH CAROLINA Harnett County File Number In The General Court Of Justice District Court Division Name of Plaintiff(s) VERSUS Name of Defendant(s) FINANCIAL AFFIDAVIT OF Plaintiff Defendant (for use in Parent Coordinator cases only) (The presiding judge may require this form to be completed) Employer: Employer's Address: I am paid: Weekly Employer Phone No. Bi-weekly Monthly Other Last Taxable Year Adjusted Gross Income: $ Current Monthly Gross Income before Deductions: $ Current Monthly Take-Home Pay after all Deductions: $ Date of Separation $ $ $ $ $ $ Current $ $ $ $ $ $ Detail of Monthly Gross Income Monthly gross wages Investment income, interest, dividends Bonus, Commissions Alimony received Child Support received Other (overtime, social security, disability, car allowance, shift pay, vacation/holiday pay) Mandatory Monthly Deductions Federal income tax State income tax Social Security taxes Medicare taxes Retirement Garnishment Other Voluntary Monthly Deductions Heath insurance Dental insurance Vision insurance Life insurance Disability insurance Medical spending account Retirement Other Date of Separation $ $ $ $ $ $ $ Current $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ American LegalNet, Inc. www.FormsWorkFlow.com PC-4 (rev. 10/2014) District 11 ­ Parent Coordinator Page 1 of 5 County Harnett File No. Part 1 Regular Recurring Monthly Expenses Expense Rent or Mortgage payment Renter's Homeowner's Insurance Taxes not included in mortgage Routine house maintenance Electricity Gas, home heating fuel, oil Water/Sewer Garbage Cable, digital television Home phone Cell phone Internet service Yard maintenance Home security system House cleaning service Pest control services Automobile payment Automobile insurance Automobile gasoline Auto maintenance (tags, taxes, registration) Food Household supplies Pet upkeep Other Other Other Other Other Other Other Other Other Other PART 1 TOTAL $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Date of Separation $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Current date American LegalNet, Inc. www.FormsWorkFlow.com PC-4 (rev. 10/2014) District 11 ­ Parent Coordinator Page 2 of 5 County Harnett File No. PART 2 INDIVIDUAL MONTHLY EXPENSES Date of Separation Expense Self Medical insurance premium Dental/Vision insurance Uninsured Medical expenses Uninsured dental/orthodontics Uninsured prescription/OTC meds. Other uninsured medicals Other insurance premiums Work related child care Summer camp Cellular phone Eating out School lunches Newspapers/magazines Clothing and accessories Personal upkeep Laundry/Dry Cleaning Education fees/supplies Babysitting, misc. child care Extracurricular activities Church/charity donations Other Other Other Other Other Other PART II - INDIVIDUAL MONTHLY EXPENSES TOTAL $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Children $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Total $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Self Children $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Total Current date American LegalNet, Inc. www.FormsWorkFlow.com PC-4 (rev. 10/2014) District 11 ­ Parent Coordinator Page 3 of 5 County Harnett File No. PART II (Continued) INDIVIDUAL MONTHLY EXPENSES Date of Separation Expense Self Other Charitable contributions Entertainment/Recreation Club dues/assessments Allowances for child(ren) Annual vacation Gifts (birthdays, holidays) Child support for another child Spousal support Professional fees School loans Retirement Investments Savings College fund Other Other Other Other Other PART II, PAGE 2 TOTAL $ PART II, PAGE 1 TOTAL $ PART II TOTAL $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Children $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Total $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Self Children $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Total $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Current date PC-4 (rev. 10/2014) District 11 ­ Parent Coordinator American LegalNet, Inc. www.FormsWorkFlow.com Page 4 of 5 County Harnett File No. PART III DEBTS Creditor Balance DOS $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Monthly Payments $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Current Balance Due $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Monthly Payment $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ PART III $ TOTAL Date: ______________________ ____________________________________________ Plaintiff Defendant American LegalNet, Inc. www.FormsWorkFlow.com PC-4 (rev. 10/2014) District 11 ­ Parent Coordinator Page 5 of 5