STATE OF NORTH CAROLINA IN THE GENERAL COURT OF JUSTICE COUNTY OF MECKLENBURG DISTRICT COURT DIVISION ( ) ____ CVD AFFIDAVIT OF: PLAINTIFF DEFENDANT PLAINTIFF, VS. SEEKING THE FOLLOWING SUPPORT: PSS/ALIMONY CHILD SUPPORT FROM WHOM THE FOLLOWING IS SOUGHT: PSS/ALIMONY CHILD SUPPORT Number of minor children: Other dependents in home: DEFENDANT. The affiant, having been first duly sworn as to the truthfulness and completeness of this affidavit, deposes and says that the average monthly financial needs for the support of the child (ren) in this case and the affiant's MONTHLY income and expenses are as follows: INCOME INFORMATION (COMPLETE IN ALL CASES) (last 4 digits only) Second Job First Job 1. My Social Security Number is: 2. I am: Self-employed doing: Employed by: Employer's address(es): xxx-xxx- Employer's telephone(s): 3. I receive the following AVERAGE MONTHLY GROSS INCOME (based on 4.33 weeks or 2.165 bi-weekly periods per month) from the following sources: A. Wages/Salary B. Bonuses C. Commissions D. Interest/Dividends/ Investments E. Rent Income 1 F. Business Income G. Social Security $ $ - 2 H. Pension/Retirement I. Other (itemize) 3 MONTHLY GROSS INCOME: $ - 1 2 3 Complete attached Rental Expense Worksheet. Enter result on Line "E." Complete attached Business Expense Worksheet. Enter result on Line "F." Other Income includes (but is not limited to): severance pay, trust income, annuity income, capital gains, Workers Compensation benefits, Unemployment Insurance benefits, disability pay, insurance benefits, gifts, prizes and alimony and maintenance received from any person(s) not a party in this case. CCF-31 Rev. 01/04/10 Page 1 American LegalNet, Inc. www.FormsWorkFlow.com PART II - CHILD SUPPORT INFORMATION Complete PART II in ALL CHILD SUPPORT CASES 1. I have the following average MONTHLY expenses: A. Court-ordered, Separation Agreement-required or otherwise regularly-paid child support for my children not living with me (and not part of this action): Name(s) of child(ren): B. Responsibility for my other children who live with me (and not part of this action)(calculated per Guidelines): Name(s) and age(s) of other child(ren): C. Gross monthly income of other responsible parent used in "B" above (in other case): D. Monthly work-related child care costs (in this case)(100%) School year per week (42 weeks per school year ): Summer per week (10 weeks per school year ): Enter twelve month average in box at right >>>>>> E. Cost to cover child(ren) on my (or my spouse's) health insurance: Extraordinary expenses for child(ren) (itemize) F. (As defined and calculated in the Guidelines ) $ - 2. Number of nights the child(ren) spend with me each year CCF-31 Rev. 01/04/10 Page 2 American LegalNet, Inc. www.FormsWorkFlow.com THE FOLLOWING DOCUMENTATION RULES APPLY TO ALL CHILD SUPPORT AND SPOUSAL SUPPORT CASES As required by Local Domestic Rule 8.4 and 10.4, at or before 5:00 p.m. on Wednesday of the week before the start of the term when my case is scheduled, I have given or will give the opposing party (but not the court) the following so that it is received by the deadline: 1 For establishment (but not modification) of child support for persons who are hourly or salaried employees (including those who may receive bonuses and commissions in addition to their salaried income): (a) (b) (c) My pay-stubs for the three (3) months preceding the court date; and My pay-stubs showing all of my bonuses and commissions year-to-date; and Federal income tax returns filed by me or for me for the two (2) tax years preceding the court date, including all schedules and attachments, together with all year-end tax documentation (W-2 forms, 1098 forms, extension requests, etc.) for the most recent tax year if any tax return has yet to be filed; and Receipts for my work-related child-care costs for the six (6) months preceding the court date; and Documentation of the cost and the actual payment of the portion of my medical and dental insurance that covers the child(ren) who are the subject of this case. (d) (e) 2 For establishment of child support for all other persons (i.e. self-employed persons, business owners, professional practice partners, etc.) and for all Motions to Modify Child Support: (a) (b) The street address, city, and state of real property, wherever located, in which I have any interest; and If not attached to a previously-filed affidavit, evidence of my gross income from all sources for the previous three (3) months, including, but not limited to: salaries, wages, commissions, bonuses, severance pay, pensions, interest, trust income, annuities, capital gains, Social Security benefits, Workers Compensation benefits, unemployment insurance benefits, disability pay, insurance benefits, gifts, prizes, alimony or maintenance received from persons other than the parties to the instant action; and Page 3 CCF-31 Rev. 01/04/10 American LegalNet, Inc. www.FormsWorkFlow.com (c) Evidence of the above-captioned income shall include, but not be limited to, the following: pay stubs, vouchers, employee benefit statements, stock option statements, company financial statements (if I am self-employed), company tax returns or Schedule "C" (if I am self-employed); and Statements for the previous three (3) months evidencing all of my accounts in banks, credit unions, brokerage accounts and other financial institutions for which the I have been a signer; and A listing of all of my outstanding debts, together with written documentation or account statements for each creditor indicating the principal balance currently owed and the payment terms; and Federal tax returns filed by me or on my behalf, including all schedules and attachments (W-2 forms, 1099 forms, etc.) for the past two (2) years, together with all year-end tax documentation (W-2 forms, 1098 forms, 1099 forms, extension requests, etc.) for the most recent tax year in the event the tax return has yet to be filed; and All personal financial statements I gave anyone, anywhere, during the previous two (2) years; and Receipts for work-related child-care costs for the six (6) months preceding the court date; and Documentation of the cost of, and the actual payment of, the portion of my medical and dental insurance that covers the child(ren) who are the subject of this case. (d) (e) (f) (g) (h) (i) THE DOCUMENTATION REQUIRED FOR ALL PSS AND ALIMONY CASES SHALL BE AS SPECIFIED IN #2 ABOVE(captioned "For establishment of child support for all other p