FORM 4 NORTH CAROLINA 28th JUDICIAL DISTRICT BUNCOMBE COUNTY IN THE GENERAL COURT OF JUSTICE DISTRICT COURT DIVISION FILE NO.____________ FINANCIAL AFFIDAVIT OF: Plaintiff Defendant PARTY SEEKING SUPPORT Plaintiff Defendant SUPPORT SOUGHT FROM Post Separation Alimony Child Support * Plaintiff – DOB: ____________________ vs. Defendant – DOB ___________________ DATE OF MARRIAGE _________________ DATE OF SEPA RATION _______________ THE UNDERSIGNED, having been first duly sworn as to the truthfulness and completeness of this affidavit, deposes and says: The names and ages of the children currently residing with me, or which may come to reside with me for which support is sought: Name___________________ Age _____ Name____________________ Age ________ Name___________________ Age _____ Name____________________ Age ________ * If this case is for Guideline Child support only, COMPLETE ONLY PART 1, sign and have notarized. PART 1: INCOME A. I am paid weekly: every other week; twice monthly; monthly; other I have gross monthly income from all sources as follows: INCOME Wages Overtime Commissions Bonus Interest Dividends Trust fund Social Security benefits Pension, Disability or Retirement income Business profit Rental Income Child support & alimony Other: TOTAL GROSS INCOME MONTHLY AMOUNT My present place of employment is at _______________________. If not employed, my last regular job was at _______________________ and I worked there until _________________. Page 1 of 5 American LegalNet, Inc. www.USCourtForms.com I have ; have not ; received substantially the same income for the past 12 months. If not substantially the same, explain the reason for the change: ______________________________________________________________________________ ________________________________________________________________________ Monthly costs for work related childcare costs $_______________ Monthly costs for the children’s health insurance premiums $________________ My other pre-existing child support payments for other children are $____________ Monthly extraordinary expenses for the children, if any $_______________ Since the date of my separation from my spouse, I have provided support in the total sum of $______ for my minor child(ren) living with my spouse and support in the sum of $_______ for my spouse. To the best of my knowledge, information and belief, my spouse earns $________ monthly. When I last knew exactly what my spouse’s income was, he or she earned $_______ monthly in ____________(month), ______________(year). A copy of my latest payroll stub or voucher is attached hereto. STOP HERE IF THE ONLY ISSUE IN THIS CASE IS GUIDELINE CHILD SUPPORT PART 2: ADDITIONAL INCOME A. If your expenses listed in PART 3 (below) exceed your income, where did you receive the additional income to make up the difference? State the amounts, the dates and from whom you received those funds. AMOUNT DATE FROM WHOM RECEIVED PART 3: REAL ESTATE AND OTHER ASSETS A. I own real estate individually with an approximate gross value of $____________ and with a mortgage balance of $___________. B. My spouse and I own real estate together, having an approximate gross value of $____________ with a mortgage balance of $___________. C. I own vehicles individually having an approximate gross value of $_____________, with an approximate debt remaining of $_____________. D. My spouse and I own vehicles having an approximate gross value of $_____________, with an approximate debt remaining of $_____________. E. I own other assets individually (including cash) totaling $_________ and I have other debts individually totaling $__________. F. I own other assets with my spouse (including cash) totaling $___________ and we have other joint debts totaling $_____________. Page 2 of 5 American LegalNet, Inc. www.USCourtForms.com PART 4: EXPENSES FOR CHILDREN AND/OR SELF A. The amounts listed as follows are the average monthly amounts of expenses, needs and anticipated expenses for my support and/or the support of our children who live with me now or who may come to live with me. (Do not include items deducted from your paycheck) ACTUAL/ANTICIPATED INDIVIDUAL NEEDS & EXPENSES SELF ACTUAL CHILDREN ANTICIP. ACTUAL NOTES ANTICIP. Food at home Food away from home (school , work, etc) Clothing – purchase Clothing – laundry & dry cleaning Cosmetic, shampoo, personal care Tobacco and alcohol Medical insurance Dental Insurance Uninsured Doctor bills Uninsured appliances (e.g. glasses) Uninsured hospital bills Uninsured prescription drugs Uninsured over the counter drugs Uninsured dental bills Uninsured orthodontic bills Other uninsured expenses Child care – day care Baby sitters Educational expenses – tuition Educational expenses – supplies & books Educational expenses – insurance Educational expenses – fees Educational expenses – pictures Educational expenses – lunches Haircuts Child support paid regularly Vacations Memberships Admissions (e.g. movies, sports, etc) Professional dues and licenses Children’s allowance Children’s activities and lessons Birthday gifts Christmas gifts Special gifts Other gifts Church donations Other donations Insurance: life, disability, accident Other: TOTAL INDIVIDUAL Page 3 of 5 American LegalNet, Inc. www.USCourtForms.com B. FIIXED MONTHLY EXPENSES SHELTER ACTUAL ANTICIPATED NOTES ACTUAL ANTICIPATED NOTES ACTUAL ANTICIPATED NOTES ACTUAL ANTICIPATED NOTES Rent House payment Taxes Insurance Other: TOTAL SHELTER UTILITIES Electricity Water and sewer Cable TV Heat Telephone Other TOTAL UTILITIES TRANSPORTATION Car payments Gasoline Maintenance and repairs Insurance Registration TOTAL TRANSPORTATION OTHER FIXED EXPENSES TOTAL OTHER FIXED EXPENSES TOTAL OF ALL FIXED MONTHLY EXPENSES $____________ PERCENTAGE OF FIXED EXPENSES APPLIED TO CHILDREN AND SELF: Self Children %_____________ = $__________________ %_____________ = $__________________ Page 4 of 5 American LegalNet, Inc. www.USCourtForms.com C. MONTHLY PAYMENTS ON DEBTS (not deducted from paycheck) Please list debts to bank or credit cards, stores, finance companies or any other indebtedness. DEBTS NAME OF CREDITOR Monthly Payment $ Amount in Arrears Named Debtor Joint, H / W Party Making Payment Balance Due on Account TOTAL MO. DEBTS D. PAYROLL DECDUCTIONS: # of exemptions on the W4 tax form (including me) ______. I have regular itemized monthly deductions from gross income as follows: MONTHLY DEDUCTIONS Federal income taxes State income taxes Social Security Retirement Dental insurance Car payments United Way Medical insurance Life, disability, accident insurance Credit Union Debt payment Child support Other deductions: MONTHLY AMOUNT TOTAL My total monthly net income (gross income less deductions) is $_________________ AFFIDAVIT OF COMPLETENESS AND UNDERSTANDING I do not have any income or employment other than that listed in this affidavit. True and accurate copies of the latest personal State and Federal Income tax returns which I have filed, are attached to this affidavit, together with a copy of my latest payroll stub or voucher. True and accurate copies of all financial statements submitted by me to any lending institution in the past two years are attached to this affidavit. I have read my answers to this affidavit and before signing it, I have allowed my attorney to read it. I have also asked my attorney to explain any parts of this affidavit that I do not understand before signing it. I understand that the Rules of Court require me to completely and honestly answer all parts of this affidavit and that it will be used in Court. I also understand that there are many sanctions, which the Court may impose on me for failing to complete this affidavit, and I have discussed them with my attorney. ____________________________ Plaintiff/Defendant Sworn and subscribed before me the _____ day of ________________, 20____. Notary Public ____________________________ My commission expires:_______________ Page 5 of 5 American LegalNet, Inc. www.USCourtForms.com