DISTRICT COURT OF WYANDOTTE COUNTY, KANSAS CIVIL COURT DEPARTMENT IN THE MATTER OF: ____________________________________________ Petitioner CASE NO._______________ DIVISION NO.___________ CHAPTER 60 _____________________________________ Respondent DOMESTIC RELATIONS AFFIDAVIT OF: __________________________________________________ (Name) 1. Mother’s Residence ____________________________________________________________ Mother’s XX-XX-______ _____________________ Soc. Security # XXX-XX-_________ Year of Birth Day Time Telephone 2. Father’s Residence _____________________________________________________________ Father’s XX-XX-_______ ___________________ Soc. Security # XXX-XX-_________ Year of Birth Day Time Telephone 3. Date of Marriage: ________________________ 4. Number of Marriages: ____________ ______________ Mother Father 5. Number of children of the relationship: _________________________ 6. Names, birth dates and ages of minor children of the relationship: Name Year of Birth Age Custodian ______________________ XX-XX-___________ _____________ _______________________ ______________________ XX-XX-___________ _____________ _______________________ ______________________ XX-XX-___________ _____________ _______________________ ______________________ XX-XX-___________ _____________ _______________________ 7. Names, and ages of other minor children of previous relationships and facts as to custody and support payments paid or received, if any: Name Year of Birth Custodian Support Payment Paid/Rec’d __________________ XX-XX-______ ____________ $_______________ __________ __________________ XX-XX-______ ____________ _______________ __________ __________________ XX-XX-______ ____________ _______________ __________ __________________ XX-XX-______ ____________ _______________ __________ 8. Mother is employed by _____________________________________________________ _____________________________________________________ Father is employed by ______________________________________________________ ______________________________________________________ (Name and address of employer(s) American LegalNet, Inc. www.FormsWorkflow.com Monthly income as follows: A. Wage Earner Mother 1. Gross Income 2. Other Income 3. Subtotal Gross Income 4. Federal withholding (Claiming ____exemptions) 5. Federal Income Tax 6. OASDHI (Social Security) 7. Kansas Withholding 8. Subtotal Deductions 9. Net Income Father $________________ ________________ ________________ ________________ $________________ ________________ ________________ _________________ _________________ _________________ _________________ _________________ _________________ ________________ ________________ ________________ ________________ ________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ __________________ __________________ __________________ __________________ _________________ _________________ _________________ _________________ B. Self-Employed 1. Gross Income from self-employment 2. Other Income 3. Subtotal Gross Income 4. Federal Withholding (Claiming _____ exemptions) 5. Self-Employment Tax 6. Estimated Tax Payments (Claim _______ exemptions) 7. Federal Income Tax 8. Kansas Withholding 9. Subtotal Deductions 10. Net Income (Line B.3 minus Line B.9) Pay Period: _______________________________ Mother ______________________________ Father 9. The Liquid assets of the parties are: Item Amount A. Checking Accounts (Do not list account numbers): _____________________ $____________________ _____________________ $____________________ B. Savings Accounts (Do not list account numbers): _____________________ $____________________ _____________________ $____________________ C. Cash Mother $____________________ Father $____________________ D. Other _____________________ $____________________ _____________________ $____________________ Joint of Individual (Specify) _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ American LegalNet, Inc. www.FormsWorkflow.com 10. The monthly expenses of each party are: (Please indicate with an asterisk all figures which are estimates rather than actual figures taken from records.) A. Item 1. 2. 3. Mother (Actual or Estimated) Father (Actual or Estimated) Rent (if applicable) Food Utilities/services: Trash Service Newspaper Telephone Mobile Phone Cable Gas Water Lights Other 4. Insurance: Life Health Car House/Rental Other 5. Medical and dental 6. Prescriptions drugs 7. Child Care (work-related) 8. Child Care (non-work-related) 9. Clothing 10. School expenses 11. Hair cuts and beauty 12. Car Repair 13. Gas and Oil 14. Personal property tax $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ 15. Miscellaneous (Specify) _____________________ _____________________ _____________________ _____________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ 16. Debt Payments (Specify) _____________________ _____________________ _____________________ _____________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ Total $_________________ $_________________ American LegalNet, Inc. www.FormsWorkflow.com Show house payments, mortgage payments, etc., in Section 10.B. B. Monthly payments to banks, loan companies or on credit accounts: (indicate actual or estimated monetary amount in each column, use asterisk for secured.) DO NOT LIST ANY PAYMENTS INCLUDED IN PART 10.A ABOVE. Creditor When Incurred Amount of payments _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________ _________ _________ _________ _________ _________ _________ __________ __________ __________ __________ __________ __________ __________ Date of last payment Balance _____________ $___________ _____________ $___________ _____________ $___________ _____________ $___________ _____________ $___________ _____________ $___________ _____________ $___________ Subtotal of Payments Total Responsibility Mother Father $__________ $___________ $__________ $___________ $__________ $___________ $__________ $___________ $__________ $___________ $__________ $___________ $__________ $___________ $__________ $___________ $__________ $___________ C. Total Living Expenses Mother (Actual or Estimated) 1. 2. 3. 4. Total funds available to Mother and Father (form No. 8) Total needed (from No. 10.A and B) Net Balance Projected Child Support Father (Actual or Estimated) $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ D. Payments or contributions received, or paid, for support of others. Specify source and amount. Source ___________________________(+/-) ___________________________(+/-) ___________________________(+/-) ___________________________(+/-) Mother $_________________ $_________________ $_________________ $_________________ Father $_________________ $_________________ $_________________ $_________________ 11. How much does the party who provides health care pay for family coverage? $_________________ per ___________. How much does it cost the provider to furnish health insurance only on the provider? $_________________ per ___________. American LegalNet, Inc. www.FormsWorkflow.com FURNISH THE FOLLOWING INFORMATION IF APPLICABLE. 12. Income and financial resources of children. Income/Resources __________________________________ __________________________________ __________________________________ __________________________________ Amount $_____________________ $_____________________ $_____________________ $_____________________ 13. Child support adjustments requested. Mother Long Distance Parenting Time Costs Parenting Time Adjustment Income Tax Considerations Special Needs Agreement Past Majority Overall Financial Condition $__________________ $__________________ $__________________ $__________________ $__________________ $__________________ Father $________________ $________________ $________________ $________________ $________________ $________________ 14. All other personal property including retirement benefits (including but not limited to qualified plans such as profitsharing,pension, IRA, 401{k}, or other savings-type employee benefits, non-qualified plans, and deferred income plans), and ownership (joint or individual), and actual or estimated value. Amount Joint or Individual (Specify) ___________________________________________ $_____________ $_________________ ___________________________________________ $_____________ $_________________ ___________________________________________ $_____________ $_________________ ___________________________________________ $_____________ $_________________ THE FOLLOWING NEED NOT BE FURNISHED IN POST JUDGMENT PROCEDURES 15. List real property identified as to description, ownership (joint or individual) and actual or estimated value. Property Description Ownership Actual/Estimated value _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 16. Identify the property, if any, acquired by each of the parties prior to marriage or acquired during marriage by a will or inheritance. Source of Actual/ Property Description Ownership Ownership Estimated value _____________________________________________________________________________________________ _____________________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 17. List debt obligations, including maintenance, not listed in Section 10.A or 10.B above, identified as to name or names of obligor or obligors and obliges, balance due and rate at which payable; and, if secured, identify the encumbered property. Debt Balance Payment Encumbered Obligation Obligor Obligee Due Rate Property _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 18. List health insurance coverage and the right, pursuant to ERISA §§ 601-608, 29 U.S.C. §§ 1161-1168 (1986), to continued coverage by the spouse who is not a member of the covered employee group. Health Insurance _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ COBRA Continuation Yes No Unknown _________ ___________ ___________ _________ ___________ ___________ _________ ___________ ___________ _________ ___________ ___________ _________ ___________ ___________ _________ ___________ ___________ VERIFICATION STATE OF _____________________) COUNTY OF ___________________) I swear or affirm under penalty of perjury that the information presented in this affidavit is true and complete. ______________________________ Date Signed _____________________________________________________ Signature Subscribed and sworn this _____day of __________________________, 20____. _______________________________________ Notary Public My Appointment Expires: American LegalNet, Inc. www.FormsWorkflow.com DISTRICT COURT OF WYANDOTTE COUNTY, KANSAS CIVIL COURT DEPARTMENT IN THE MATTER OF: ____________________________________________ Petitioner CASE NO._______________ DIVISION NO.___________ CHAPTER 60 _____________________________________ Respondent EMPLOYER VERIFICATION FORM (BOTH PARTIES MUST HAVE THEIR EMPLOYER COMPLETE THIS FORM) Employee Name _______________________________________________________________________________ Current Home Address __________________________________________________________________________ _____________________________________________________________________________________________ Employer Name _______________________________________________________________________________ Work Location and address _______________________________________________________________________ _____________________________________________________________________________________________ NORMAL PAYMENT PERIOC: (circle one) weekly, every two weeks, semi-monthly, monthly, other (specify) _____________________________________________________________________________________________ HOURLY WAGE GROSS INCOME Itemized all deductions from income Federal income tax State & Local Income tax Federal social security or R.R. retirement tax Other amounts required by law to Be withheld (specify) NET DISPOSABLE INCOME $______________________ $______________________ /Month $______________________ /Month $______________________ /Month $______________________ /Month $______________________ /Month $______________________ /Month $______________________ /Month HEALTH INSURANCE: Does the employee now have health insurance through your company which covers dependent children not living with the employee? YES _____ No _______ If no, Is it available? YES _____ No _______ List dependents claimed under employee’s health insurance _____________________________________________________________________________________________ What is the cost to provide such coverage for the children ONLY? $__________________________ List name of insurance carrier _____________________________________________________________________________________________ _________________________________________________________ Signature and Title of Employer providing above information ________________________________ Date American LegalNet, Inc. www.FormsWorkflow.com DISTRICT COURT OF WYANDOTTE COUNTY, KANSAS CIVIL COURT DEPARTMENT IN THE MATTER OF: ____________________________________________ Petitioner CASE NO._______________ DIVISION NO.___________ CHAPTER 60 _____________________________________ Respondent CHILD CARE VERIFICATION PARENT INFORMATION: Complete the top portion of this form and have your child care provider complete the remainder. Name: _______________________________________________________________________________________ Name(s) and age(s) of child(ran) involved in this case __________________________________________________ _____________________________________________________________________________________________ Are you receiving financial assistance for child care from Federal or State agency? Yes No If yes, please state the agency and the amount you are receiving. _________________________________________ _____________________________________________________________________________________________ CHILD CARE PROVIDER INFORMATION: Please attach a schedule of your most recent child care rates. The child Care Provider must complete the remainder of this form for the above named child(ren). Name of provider: ______________________________________________________________________________ Address: _____________________________________________________________________________________ Name and age of child School Year Rates Avg. No. of Hrs/Wk Hrly Rate Total Wkly Rate ___________________________ $______________ $________________ $____________ $_____________ ___________________________ $______________ $________________ $____________ $_____________ ___________________________ $______________ $________________ $____________ $_____________ ___________________________ $______________ $________________ $____________ $_____________ Name and age of child ___________________________ ___________________________ ___________________________ ___________________________ Sunner Rates $______________ $______________ $______________ $______________ Avg. No. of Hrs/Wk $________________ $________________ $________________ $________________ Hrly Rate $____________ $____________ $____________ $____________ Total Wkly Rate $_____________ $_____________ $_____________ $_____________ Do you require payment for service even when children are absent to guarantee a position in you center? Yes No If yes please explain: ____________________________________________________________________________ Does Federal or State agency contribute all or a portion of these child care services? Yes No THE ABOVE INFORMATION IS PROVIDED TO ENABLE THE DISTRICT COURT TO ACCURATELY REPORT CHILD CARE COSTS IN MAKING A CHILD SUPPORT MODIFICATION. I CERTIFY THAT THE ABOVE INFORMATION IS TRUE, ACCURATE, AND COMPLETE. _______________________________________________________ SIGNATURE AND TITLE OF PROVIDER ____________________________ DATE American LegalNet, Inc. www.FormsWorkflow.com