STATE OF NORTH CAROLINA GENERAL COU RT OF JUSTICE County of _________________ DISTRICT COURT DIVISION Case No.: _____________ __________________________ Plaintiff/petitioner VS. CHILD SUPPORT AFFIDAVIT __________________________ Defendant/respondent Pursuant to the Rules of Court adopted for the District, both parties ar e required to complete the following document, swear to its accuracy before the Clerk of Court or a Notary, a nd have it available for examination by the court and opposing parties by the date of the hearing. Employment information: Your Social security number: Employed by: How long: Pay period: [ ]weekly [ ]two weeks [ ]bi-monthly [ ]monthly [ ]other: Gross Monthly income, before any deductions, from all sources: $ [Monthly income is computed by multiplying gross weekly income (before deductio ns) by 4.3] Monthly insurance paid by you attributable only to your children: $ Are you supporting other children? [ ]yes [ ]no How many?___ Amount you actually pay per month for other children through court: $ Amount you acutally pay per month for other children out of court: $ Are you paying for out-of-home child care? [ ] yes [ ] no Amount you actually pay per month which is work related: $ You must bring with you to court the following additional documents: 1. A copy of your most recent federal and state tax return; 2. A copy of a recent pay statement showing your current gross pay and ded uctions. 3. An executed employer certification of earnings. (Forms are availabe in Clerks office). Your child support obligation will be computed according to the presumpt ive guidelines as required by North Carolina law unless you have specifically pled grounds for departing from the presumptive amount. If you contend that the amount should not be the presumptive amount, you must, before the date of the hearing, file a statement setting out the reasons and complete a detailed affidavit of earnings and living expenses on a form available in the office of the Clerk of Superior Court. AFFIDAVIT I hereby certify that the foregoing is true, complete and accurate to th e best of my knowledge. I do not have any income other than that listed in this affidavit. Signature:_________________________________ The above named person appeared before me this _____ day of ____________ _________, 19____, and swore under oath that the information provided in this affidavit was the truth. Signature of official administering oath: _________________________________ [SEAL] ( ) Clerk of Court ( ) Magistrate ( ) N otary: com. exp. date___________________ 5th Dist. [MSWord2000] Rev 7/20/2000 American LegalNet, Inc. www.USCourtForms.com