Form16(a) (Rev. 02/11) Failure to complete this report and to provide documentation may result in the dismissal of your petition or the entry of an Order adverse to your interests. The Family Court of the State of Delaware FINANCIAL REPORT 1. Personal Information Name Address Date File Number Petition Number Home Phone # Date of birth The child(ren) for whom support is sought is(are): Name Name date of birth date of birth Name Name date of birth date of birth Work Phone # 2. Income Information Employers Name: Date employment began: EIN (Federal Employer Identification) Number for Employer: Address: If unemployed, explain circumstances: If unemployed (or employed less than full time), what was your last full time Occupation? Former Employers Name: Reason for leaving: Income Type Wage/salary - including overtime Tips, commissions and bonuses Wage/salary - second job Employer provided housing/transp. Military rank: $ Amount per per per per BAH BAS Other allowances Geographic cost of living stipend Gross Proceeds from self-employment Net Income from self-employment Interest, dividends, investments Social Security (SSD or SSR) Supplemental Security Income (SSI) Unemployment or Worker's Compensation Other pension, retirement or disability Alimony Received per per per per per per per per per per per per Date employment began: Rate of pay: $ per Required Documentation Pay stubs, tax return, W-2 form Pay stubs, tax return, W-2 form Pay stubs, tax return, W-2 form 1099 L.E.S. statement L.E.S. statement L.E.S. statement Pay stubs, letter from employer IRS Schedule C, 1099 forms Tax return, IRS Schedule C Tax return, 1099 forms Social Security statement Social Security statement Check stub, insurer statement Tax return, 1099, payor letter Tax return, Court Order Bring copies of your last three pay stubs and most recent tax return with all schedules and W-2 statements to every mediation conference and hearing. If self employed, the Schedule C from your last tax return with all 1099 forms is also required. Other documents may be needed depending on the facts of your case. Attachment checklist: Pay stubs Tax Return(s) W-2 Form(s) 1099 Form(s) Health Insurance Schedule C Childcare Other 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Form16(a) (Rev. 02/11) 3. Deductions Voluntary pension deductions are limited to 3% of gross income. `Other mandatory' is amounts withheld by law or as a condition of employment. Life insurance is deductible only if required by Court Order or agreement of the parties. Deduction Type Amount Required Documentation Medical Insurance Union Dues Pension Contribution Disability Insurance Alimony Paid Other mandatory deductions $ per per per per per per Pay stubs, brochure Pay stubs Pay stubs Pay stubs Court Order Pay stubs 4. Other Obligations List any other children (but not stepchildren) in your household or for whom you have been ordered to pay support or do provide support. Be prepared with documentation such as court orders, cancelled checks and money orders. Name Name date of birth date of birth Name Name regularly date of birth date of birth 5. Additional Primary Expenses Child care expenses incurred by either parent for the benefit of the children of this obligation receive consideration in the child support formula. Private school tuition and expenses receive consideration under some circumstances. Expense Provider Amount School Year childcare Summer childcare Private School $ per per per 6. Medical Support Are you currently providing health insurance for these children (listed in Section 1)? If yes, how are they covered? Through my employer, Private contract, or If not, is coverage available to you through employment? If currently provided or currently available but not yet purchased: What is the out-of-pocket cost for coverage of the employee only? What is the cost for coverage of both the employee and any dependent children? What is the name of the Insurance Company? Yes No No per per By my spouse. Yes $ $ * * * TO RECEIVE MAXIMUM CREDIT, DOCUMENTATION OF THE COST OF INSURANCE IS CRITICAL * * * 7. Parenting Time Adjustment Does the child(ren) live with you? Yes No Is there a Court Order or written agreement that grants the parent from who support is sought more than 109 overnights with the Yes No child(ren) each year? 110 to 132 133 to 150 151 to 164 165 to 174 175+ If yes, how many overnights? * * * PLEASE BRING ORDER OR WRITTEN AGREEMENT WITH YOU TO COURT * * * State of Delaware County of New Castle Kent Sussex SIGNED AND SWORN (OR AFFIRMED) before me this ______ day of ______________________, _________ PETITIONER RESPONDENT NAME OF AFFIANT NOTORIAL OFFICER - 29 Del.C. §4323(a) 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com