MONTANA CHILD SUPPORT GUIDELINES FINANCIAL AFFIDAVIT INSTRUCTIONS FOR COMPLETING THIS FORM: It must be signed and notarized. Provide complete information, attaching additional pages if needed. If a question or statement does not apply to you, DO NOT LEAVE BLANK. Instead, mark it as "Not Applicable" or uN/A." Your social security number is requested on this form. No state law requires you to give this number. Courts and administrative agencies use this number to track cases and to apply payments to the correct case. A. PERSONAL INFORMATION Full Name: Social Security #: Home Address: Telephone #: Date of Birth: Mailing Address: Case Number: Driver's License #: What is your tax filing status? D Single 0 Married, joint 0 Married, separate D Head of Household List the people you claim as tax exemptions _ If you are married and file taxes jointly, please provide your current spouse's annual income so that tax credits may be calculated accurately. $ _ Did you finish high school? DYes 0 No If no, indicate highest grade completed: List all schools attended following high school. Include training school, college or university, trade school. School Name Course of Study Completion Date Degree/Diploma B. CHILDREN 1. List all of your natural and adopted children (do not include stepchildren) Child's Full Name Date of Birth Month/Dav/Year Are you ordered to pay support for this child? Who does child live with? o No DYes $ amount/month o No DYes $ amount/month o No o Yes $ amount/month o No DYes $ amount/month o No o Yes $ amount/month o Yes $ amount/month ONo ATTACH A COPY OF ANY ORDER REQUIRING CHILD SUPPORT TO BE PAID FOR THESE CHILDREN. CS-404.6A (Rev. 3/07) American LegalNet, Inc. www.FormsWorkflow.com 2. Complete the table below for all expenses you pay and benefits you receive on behalf of all children shown in the previous table. Attach proof for the items listed below. Do NOT list amounts paid by other parent. Child's First Name Annual Day Care Costs Annual Unreimbursed Medical Expenses Annual Dependent's Benefits Received" How many days does child spend with you per year?"" Annual Miles Driven for Long Distance Parentina Other Transportation Costs for Long Distance Parenting""" • For example - SOCial Security Benefits "" The majority of a 24 hour period the children are in your control """ Do not include lodging, food and entertainment 3. Do you receive reimbursement for day care expenses? 0 No 0 Yes $ 4. If any of the children listed above have ongoing medical expenses, please describe. ---"month reimbursement 5. Do you have health insurance available to you through employment or other group? 0 No 0 Yes If no, skip to Section C. If yes, to have the cost included in your child support calculation, you must do one of the following before the final order is entered: A. Prove that you currently have insurance coverage in effect for the children; or B. Obtain verification from the insurance carrier that you have paid a premium with the intent to enroll the children. Name everyone who is covered by this policy: Regardless of whether your children are covered, complete the following: Insurance Co. Name: Address: Policy Number: Certificate Number: $---- Total cost of health insurance premium per month, including your children (whether or not you and the children are currently enrolled). Adult's portion of premium. $---- Child(ren)'s portion of premium. $,---- Portion of premium to be paid by you each month. $,---- Portion of premium to be paid by employer or other group each month. $---- 2 American LegalNet, Inc. www.FormsWorkflow.com C. EMPLOYMENT 1. List your current or most recent employer(s) first and your past two employers: Employer's Name, Address, and Telephone Number Dates of Employment Average Hours Worked and Current or Endina Pay From - - hours/week To _ _ pay/hour From - - hours/week To _ _ pay/hour From - - hours/week To P·Permanent T-Temporary S-Seasonal _ _ pay/hour 2. What kinds of work do you/did you do for your employer(s)? 3. Do you belong to a union? 0 No 0 Ves 4. Are you currently a student? 0 No 0 Yes If yes, provide a copy of your most recent registration statement showing tuition, fees, etc., and a copy of your most recent financial aid award letter. Please provide your expected date of If yes, name of union local, address, and amount of monthly dues: graduation: 5. Is there any reason, such as disability, that prevents you from being able to work full-time? 0 No provide a statement from your doctor or the social security administration. 6. Do you receive workers' compensation or occupational disease benefits? 0 No 0 Yes If no, are you currently seeking workers' compensation benefits or occupational disease benefits? 0 No 0 Yes If yes, who pays those benefits and what is your claim number: 7. Are you currently receiving unemployment benefits? 0 No 0 Yes If yes, name of state or agency paying those benefits: 8. If unemployed or employed parHime, have you made any efforts to find full-time employment? If no, why not? If yes, describe your job search: 0 Yes If yes, _ _ 0 No 0 Yes _ _ 3 American LegalNet, Inc. www.FormsWorkflow.com D.INCOME 1. List all income which you receive or have received in the last 12 months. Income Source Annual Amount Income Source Gross Wages Public Assistance Unemployment Veterans' Disability Workers' Compensation Spousal Support Social Security Benefits Contract Receipts Retirement Rental Income Interest/Dividend Income Fringe Benefits/Bonuses Reimbursements Profit (Loss) from Self-emnlovment Educational Grants Annual Amount Other: 2. Do you receive any non-cash benefits from your employer, such as housing, groceries, meal, car or truck, utilities, phone service? 0 No 0 Yes If yes, describe the non-cash benefit you receive, how often you receive iI, and the value of the benefit: 3. If you are self~employed, describe your self-employment activities: How many hours per week do you spend engaged in self-employment activities? Is your self-employment the primary source of your income for meeting your living expenses? 0 No 0 Yes 4. Have you, in the past 12 months, received any prize, award, settlement or other one-time cash payment? No 0 Yes If yes, describe the payment, inclLiding the amount and its present location and value. 5. ATTACH COPIES OF YOUR PAY STUBS FOR THE LAST THREE (3) MONTHS. ALSO ATTACH COMPLETE COPIES OF YOUR FEDERAL INCOME TAX RETURNS, including all schedules filed and W-2 forms, for the last three (3) years. If you do nol have pay stubs or W-2 forms, provide employer's statement. If you are self-employed, you must provide copies of your individual returns as well as the business (partnership or corporation) returns for the last three (3) years. o E. DEDUCTIONS AND EXPENSES 1. List deductions from gross wages, including costs for required uniforms or work related equipment. Attach pay stubs and proof of expenses. DEDUCTION AMOUNT HOW OFTEN PAID? Federal Income Tax State Income Tax FICA and Medicare Mandatorv Retirement Renuired Work Related Costs 2. Has a court ordered you to pay alimony? 0 No 0 Yes If yes, attach copy of order and proof of payments. 4 American LegalNet, Inc. www.FormsWorkflow.com 3. Do you have any extraordinary medical expenses for yourself, not reimbursed by insurance, your employer, or another, which are necessary for you to maintain your health or your earning capacity? o No 0 Yes If yes, list yearly expenses and attach proof: 4. Please list any necessary expense you pay for in-home nursing care to enable you to work and for whom the expense is paid: 5. Is your contribution for retirement mandatory? 6. List employment related expenses not shown elsewhere: 7. Has a court ordered you to make payments for restitution, damages, etc.? order and proof of payments. 8. Please attach a list of monthly expenses if you feel it is important to show your financial situation. o No 0 Yes o No 0 Yes If yes, provide a court F. ANTICIPATED CHANGES / ADDITIONAL COMMENTS 1. Please list any changes you expect in your or your child(ren)'s circumstances during the next 18 months which would affect the calculation of child support? 2. Additional Comments (a separate sheet may be attached): VERIFICATION: You must sign this in front of a Notary Public. STATE OF COUNTY OF I declare, subject to penalties for perjury and false swearing, that I have read the foregoing affidavit and that the information contained in it and all attachments to it is true and correct to the best of my knowledge, information and belief. Date Affiant Signed and sworn before me, a Notary Public for this State, on the date and at the place written above. (SEAL) NOTARY PUBLIC Print Name: Residing at: My Commission Expires: 5 _ _ _ American LegalNet, Inc. www.FormsWorkflow.com