ARIZONA SUPERIOR COURT, PIMA COUNTY Assigned to: Petitioner, CASE NO. CHILD SUPPORT FINANCIAL AFFIDAVIT and Respondent. NAME: _________________________________________________ BIRTH DATE: _____________________ ADDRESS: __________________________________________________________________________________ MONTHLY EXPENSES: INCOME: Child(ren)’s Medical & Dental Insurance Cost: GROSS PAYCHECK weekly monthly Child Care (average annually) $ twice mo. every 2 weeks OTHER MONTHLY INCOME: Pension/Retirement $ Social Security/SSI $ Dividends/Interest $ GA/AFDC $ Spousal Maintenance $ Rec'd. for minor child(ren) not of this marriage under your care $ Other: $ Support paid to former spouse Support paid for other children Education Expenses Extraordinary Child Expenses: (itemize) TOTAL OTHER INCOME $ VISITATION DAYS PER YEAR: Summer periods Holiday & School break periods Weekend periods Midweek periods Other: TOTAL DAYS: 1 to-child support affidavit.form Revised 01.03.08 American LegalNet, Inc. www.FormsWorkflow.com Present Occupation: ___________________________________________ Starting Date: __________ Name, Address, phone number of present employer: Prior Occupation: ______________________ Starting Date: ______ Monthly pay: ______Ending Date: _______ Name, Address, phone number of prior employer: If not employed, why? __________________________________________________________________________ When do you expect to work? Full name(s) and age(s) of ALL minor child(ren) residing with you: _____________________________________________________________________________________________ _____________________________________________________________________________________________ Physical defect or organic disease suffered by you or your minor children: List all bank accounts, including checking, savings, credit union, certificates of deposit, in your name or in which you have an interest: Account Number Bank/Branch Type of Account (last 4 digits) Average Balance List all stocks, shares and/or bonds in your name or in which you have an interest. _____________________________________________________________________________________________ _____________________________________________________________________________________________ Attorney fees paid to date: $ _____________________ Court costs paid to date: $ _____________________ STATE OF ARIZONA County of Pima ) ) ss. ) , being first duly sworn, deposes and says that he/she has read the foregoing Financial Affidavit and knows the contents thereof, and that the allegations therein contained are true in substance and in fact, except those made on information and belief, which are believed to be true. DATED this day of _______________________, 20 Signature: SUBSCRIBED AND SWORN TO before me this . ________________________________________ day of , 20 . My Commission Expires: ______________________________________ Notary Public Party/Attorney’s Name, Address, and Telephone: 2 to-child support affidavit.form Revised 01.03.08 American LegalNet, Inc. www.FormsWorkflow.com