STATE OF NORTH CAROLINA GENERAL COURT OF JUSTICE County of _________________ DISTRICT COURT DIVISION Case No.: _____________ EMPLOYERS CERTIFICATION OF WAGES To: The employer of ______________________________________ In order to verify the income of the above employee, you are requested to furnish the following information for use in a court proceeding by your employee. Please certify the current GROSS MONTHLY INCOME of the employee. Gross income includes the total of all compensation, including bonuses ordinarily earned, and the amount before any taxes, social security, insurance or other deductions are mad e. Please compute monthly income using the following formulae: If the pay period is weekly, multiply weekly gross income by 4.3. If the pay period is every other week, multiply gross income by 2.15. If the pay period is twice monthly, multiply the gross income by 2. 1. Current gross monthly income: $ Per month 2. Total gross income for last calendar year: $ Per year 3. Does the above include income from overtime or Bonuses bonuses? _______. If yes, please specify average $ Per month monthly amounts: Overtime $ Per month 4. For how long has this employee worked for you? You may provide here or on additional sheets any additional information necessary to accurately convey the level of income which the employee can expect to r eceive in the future. I hereby certify that the forgoing information is true, complete and acc urate to the best of my knowledge and belief. This ____ day of _____________, 19 __. _____________________________________ Signature of person representing the employer who is providing this information. _____________________________________ Name of company _____________________________________ Position of person providing information Telephone:____________________________ The employee should deliver this to the employer to be completed by the employer. The employer, after completing the form, should return it to the employee. FC 5th Dist. [MSWord2000) Rev 7/20/2000 American LegalNet, Inc. www.USCourtForms.com