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