F 3.405(M) IN THE DISTRICT COURT OF SHAWNEE COUNTY, KANSAS DIVISION _____ ______________________________ [CAPTION] vs. ______________________________ ) ) ) ) ) ) ) Case No. Document No. _____________ MINI DOMESTIC RELATIONS AFFIDAVIT OF _______________________________ (name) To be used with post-judgment Motions To Modify/Establish Child Support ONLY. 1. Your Name _______________________________________________________ First Middle Last Residence _______________________________________________________ City State _________________ XXX-XXYear of Birth Social Security Number 2. Names, SS#’s, birth dates, and ages of minor children of the marriage/relationship: Name SS Number Year of Birth Age _____________________ XXX-XX-_____ ___________ ______ _____________________ XXX-XX-_____ ___________ ______ _____________________ XXX-XX-_____ ___________ ______ _____________________ XXX-XX-_____ ___________ ______ 3. Names, SS#’s, and ages of minor children of previous marriage/relationships and facts as to custody and support payments paid or received, if any. Name ____________________ ____________________ ____________________ ____________________ Name of Custodian SS Number _____________________XXX-XX-_____ _____________________XXX-XX-_____ _____________________XXX-XX-_____ _____________________XXX-XX-_____ 4. You are employed by: Name: Address: Year of Birth __________ __________ __________ __________ Support Paid/Received __________________ __________________ __________________ __________________ __________________________________ __________________________________ __________________________________ American LegalNet, Inc. www.FormsWorkFlow.com 5. Monthly income: A. Wage Earner, Gross income B. Self-Employed, Gross income Reasonable Business Expense Self-Employment Tax $_______________ $_______________ $_______________ $_______________ 6. Work Related Child Care Expenses: A. Weekly Summer Expense $___________________ B. Name and Address of Provider _________________________________ _________________________________ Weekly School Year Expense Name and Address of Provider $___________________ _________________________________ _________________________________ 7. Father/Mother provides Health Insurance for child(ren). A. Name and Address of Health Insurance Plan:____________________________ __________________________________________________________________ B. Persons insured on plan: ____________________________________________ C. Monthly cost of health insurance: $________ Monthly cost of dental insurance: $________ Monthly cost of vision insurance: $________ Monthly cost of drug prescription insurance: $________ Increase cost of adding child(ren) to the plan: $ ________ 8. Father/Mother claims child(ren) for income tax purposes. You file taxes: _____Single _____Head of Household _____Joint _____Other 9. Child Support Adjustments requested: ____ Long Distance Parenting Time Adjustment ____ Parenting Time Adjustment ____Agreement Past Minority 10. Attached is: ____ Current Pay Stub ____ W-2 ____ Written Proof of Insurance Costs ____ Special Needs ____ Income Tax Adjustment ____ Overall Financial Condition ____ Last Year’s Tax Form ____ Written Proof of Day Care Cost ____ Other I declare under penalty of perjury under the laws of the state of Kansas that the forgoing is true, correct and complete. Executed on the _____ day of ____________________, 20__. _________________________________ Petitioner/Respondent American LegalNet, Inc. www.FormsWorkFlow.com