FORM 5 NORTH CAROLINA IN THE GENERAL COURT OF JUSTICE 28th JUDICIAL DISTRICT DISTRICT COURT DIVISION BUNCOMBE COUNTY _______-CVD- __________ ________________________________, Plaintiff AFFIDAVIT -v- (Employer Wage Affidavit) ________________________________, Defendant I, _____________________________________, (please print nam) a Pe ersonnel Officer, being duly sworn, deposes and says: 1. That I am an employee of __________________________________ [name of company] located at _____________________________________________ [provide full address]; and 2. That ________________________, the Plaintiff, or Defendant in the above entitled action, is an employee of said company; and 3. That the records attached hereto of P laintiffs, or Defendants earnings, deductions, company benefits, and length of employment are true and correct to the best of affiants information and belief. 4. That my work telephone number is ________________________. This the ____day of ______________, 20___. __________________________________ Affiant (Personnel Officer) __________________________________ Title Subscribed and sworn before me this the ___ day of ______________, _____. ________________________________ Notary Public My commission expires: ____________ American LegalNet, Inc. www.USCourtForms.com>>>> 2 FORM 5 EARNINGS INFORMATION 1. Earnings last calendar year, including bonus, if any: a. Gross: $ _____________ Net: $ _____________ insert time period, i.e., week, month, etc] . * If Employee is paid on production or commission, what is present average gross pay? insert time period, i.e., week, month, e] tc. 3. How often is employee paid? _________________ 4. Number of hours working per day? ____________ 5. Number of days working per week? ____________ 6. Deductions from gross payper p ay perio: d a. State taxes: $__________ Federal taxes: $__________ b. FICA: $__________ Medical Insurance $__________ i. How much of medical insurance premium is allocated for coverage of children? $_________ per ________. ii. Does medical insurance include medical, dental and/or other coverage? If so, what health care services are covered? _______________________________ iii. What are the terms of the deductible payments required under the medical coverage provided? ______________________________________________ 7. Number of exemptions claimed: _________ 8. Date employee last paid: _______________ 9. How many pay periods, if any, are employees earnings retained by employer? ___________ 10. Earnings this calendar yea rthrough date employee was last paid, including bonus, if any: a. Gross: $__________ Net: $__________ 11. Is employee paid a bonus? _______ (yes or no) Iyesf, expl ain: a. How bonus is computed: ________________________________________________ b. When bonus is paid: ____________________________________________________ c. Amount paid last calendar year: ______________ d. Amount paid this calendar year: ______________ 12. What pay increase, if any, has employee received in the past twelve months? _____________ 13. Nature of employment: _______________________________________________________ 14. Date(s) of Hire/service: ______________________________________________________ 15. Amount paid by employer on employees behalf for: a. Medical Insurance: $________ per ________ b. Disability Insurance: $________ per ________ c. Dues: $________ per ________ d. Retirement: $________ per ________ e. Reimbursed expenses: $________ per ________ American LegalNet, Inc. www.USCourtForms.com