Nebraska State Court Form FINANCIAL AFFIDAVIT FOR CHILD SUPPORT DC 6:5(2) Rev. 04/15 Neb. Ct. R. §§ 4-204, 4-205 IN THE DISTRICT COURT OF _________________ COUNTY, NEBRASKA (county where Complaint filed) ____________________________, (your full name) Case No. CI _____________ (case number assigned by Clerk of Court) Plaintiff, vs. ____________________________, (spouse's full name) FINANCIAL AFFIDAVIT FOR CHILD SUPPORT Defendant. STATE OF NEBRASKA ss. COUNTY OF ____________________ (county where signed) I, __________________________________, am under oath and I state that (first, middle and last name) the following information is true: 1. I filed this action for divorce. Choose one: [ ] There is no existing order for support for the minor childr(en) born to me and my spouse. OR [ ] There is currently an order for the support of the minor child(ren) of me and my spouse through: _____________________________________________ (name of court) _____________________________________________ (case number) _____________________________________________ (amount of support) _____________________________________________ (number of children) Continued on next page ... Page 1 of 6 Financial Affidavit for Child Support DC 6:5(2) Rev. 4/15 American LegalNet, Inc. www.FormsWorkFlow.com 2. I am employed at _____________________________________________. (name of employer) My current gross monthly income is $_____________________. My income (amount of income from all sources) is based on (choose one): [ ] $ _________ per hour for ___________ hours per week. (amount per hour) (number of hours) OR [ ] $___________salary per month plus monthly bonuses of (amount per month) $_____________. (average amount per month) 3. My spouse is employed at _______________________________________. (name of employer) My spouse's current gross monthly income is $_____________________. (amount of income from all sources) This income is based on (choose one): [ ] $_________ per hour for ___________hours per week. (amount per hour) (number of hours) OR [ ] $___________ salary per month plus monthly bonuses of (amount per month) $____________. (average amount per month) 4. I believe I am capable of earning more income than is currently being earned. I base this on past employment at _______________________, (name of employer) where my gross income per month was $____________________, based on (amount of income from all sources) (choose one): Continued on next page ... Page 2 of 6 Financial Affidavit for Child Support DC 6:5(2) Rev. 4/15 American LegalNet, Inc. www.FormsWorkFlow.com [ ] $_________ per hour for ___________hours per week. (amount per hour) (number of hours) OR [ ] $___________ salary per month plus monthly bonuses of (amount per month) $____________ (average amount of bonus) 5. I believe my spouse is capable of earning more income than is currently being earned. I base this on past employment at ____________________, (name of employer) where my spouse's gross income per month was $____________________, (amount of income from all sources) based on (choose one): [ ] $_________ per hour for ___________hours per week. (amount per hour) (number of hours) OR [ ] $___________ salary per month plus monthly bonuses of (amount per month) $____________. (average amount of bonus) 6. I do/do not (circle one) have health insurance available for the child(ren) through my employment at a cost of $_____________________ per month. (cost of coverage for child(ren) only) 7. My spouse does/does not (circle one) have health insurance available for the child(ren) through employment at a cost of $_____________________ per (cost of coverage for childr(en) only) month. Continued on next page ... Page 3 of 6 Financial Affidavit for Child Support DC 6:5(2) Rev. 4/15 American LegalNet, Inc. www.FormsWorkFlow.com 8. Check the box [ ] that applies: [ ] I contribute to a mandatory retirement plan. The minimum amount required as a contribution is $____________. (minimum contribution required) OR [ ] I do not contribute to a mandatory retirement plan. OR [ ] I do not have a mandatory retirement plan, but I contribute to a voluntary retirement plan. My monthly contribution is $____________. (average contribution) OR [ ] I do not contribute to a voluntary retirement plan. 9. Check the box [ ] that applies: [ ] My spouse contributes to a mandatory retirement plan. The minimum amount required as a contribution is $____________. (minimum contribution required) OR [ ] My spouse does not contribute to a mandatory retirement plan. OR [ ] My spouse does not have a mandatory retirement plan, but my spouse contributes to a voluntary retirement plan. My spouse's monthly contribution is $____________. (average contribution) OR [ ] My spouse does not contribute to a voluntary retirement plan. Continued on next page ... Page 4 of 6 Financial Affidavit for Child Support DC 6:5(2) Rev. 4/15 American LegalNet, Inc. www.FormsWorkFlow.com 10. I have other children I am supporting. Number of children: _____________. (number of other children) Children's names and years of birth: _________________________________ (name) ______________________ (year of birth) _________________________________ (name) ______________________ (year of birth) _________________________________ (name) ______________________ (year of birth) For the other child(ren) I am supporting, check the box [ ] that applies: [ ] If support is court-ordered: _____________________________________________ (method of support) _____________________________________________ (name of court) _____________________________________________ (case number) _____________________________________________ (amount of support) OR [ ] If support is not court-ordered: ____________________________________________ (method of support) _____________________________________________ (name of other parent) _____________________________________________ (gross monthly income of other parent) 11. My spouse has other children to support. Number of children: _____________. (number of spouse's other children) Continued on next page ... Page 5 of 6 Financial Affidavit for Child Support DC 6:5(2) Rev. 4/15 American LegalNet, Inc. www.FormsWorkFlow.com Children's names and years of birth: _________________________________ (name) ______________________ (year of birth) _________________________________ (name) ______________________ (year of birth) _________________________________ (name) ______________________ (year of birth) For the oth