ST ATE OF NORTH CAROLINA IN THE GENERAL COURT OF JUST ICE COUNTY OF CABARRU S DISTRICT COURT DIVISION FILE NO. Plaintiff, FINANCIAL AFFIDAVIT v. [ ] PLAINTIFF [ ] DEFE NDANT Defendant. INCOME INFORM ATION Employer:_________________________________ Employer Telephone: _______________ Employer Addres s: ____________________ ___________ Soc ial Security No:_____________ _____ L ast Taxable Year Adjusted Gross Income: ______________________________ Monthly Gross Before Deductions: ______________________________ Monthly Take Home Pay After Deductions: _______________________________ (ATTACH TO THIS AFF IDAVIT COP IE S OF THE PAS T TWO (2) MONTHS WAGE AND EARNINGS S TATEMENTS ) Other Incomes: Commissions: Investments: S ocial Sec urity: Alimony: Child Support: Other: TOTALS MONTHLY HEALTH INSUR ANCE AND OTHER CHILD PAYMENTS Total Health Insurance Pre-Existing Child Res ponsibility for Premium Costs: $___________ Support Pa yments: $_________ Other Children: $________ MONTHLY WORK REL ATED CHILD CAR E COST S Childs Name Amount Childs Name Amount NON-PRO R ATED MONTHLY EXPENSE S Item Amount Item Amount House Pa yment/Rent Household Food Supplies Heat Electricity Water Telephone Cablevision Car Pa yment House Maintenance Car Insurance Life Insurance TOTALS American LegalNet, Inc. www.USCourtForms.com>>>> 2 INDIVIDUAL MONTHLY EXPENSES SELF CHILD CHILD CHILD TOTALS Name ____________________ Name ___________________ Name _____________________ Age ___________ Age ___________ Age ___________ School & Work Lunch Medical/Dental Drugs Clothing Grooming Laundry/Cleaning Entertainment Recreation Reading Material Church Donations Gifts, Christmas, etc. Club Dues Education Allowances Vacation Gasoline Car Repair & Maintenance Eating Out Other Other Other TOTALS ASSETS AND DEBTS Asset Value Debt Balance Due Monthly Payment Real Estate Real Estate/Mortgage Vehicles Vehicle Stocks & Bonds Loans Accounts & Cash Credit Cards Other Other TOTALS I certify that the aforementioned is true, complete and accurate to the best of my ability. Sworn to and subscribed to before me this ____ day of ____________, 20_______. _________________________________ Affiant ___________________________________ Notary Public My Commission Expires: American LegalNet, Inc. www.USCourtForms.com