File No. STATE OF NORTH CAROLINA CVD COUNTY OF CUMBERLAND IN THE GENERAL COURT OF JUSTICE DISTRICT COURT DIVISION Name Plaintiff POST SEPARATION SUPPORT AFFIDAVIT VERSUS Cumberland County Domestic Rule 11.8Name Defendant Name of Domestic Case Manager * L OCAL RULES REQUIRE THAT THIS AFFIDAVIT BE COMPLETED PRIOR TO THE HEARING AND PRESENTED TO THE COURT. The r Plaintiff r Defendant named above hereby certifies under oath that the information provided below is true, accurate, and complete. I. STATUS OF CHILDREN 1. Are there children of the parties? rr Yes rr No If yes, list their name(s) and birthdate(s). Name DOB Name DOB Name DOB Name DOB Name DOB 2. Is there a Temporary Custody Order or Agreement? rr Yes rr No If yes, provide a brief summary of the parenting arrangement. 3. Do you have other children not of the parties? rr Yes rr No If yes, list their name(s) and birthdate(s). Name DOB Name DOB Name DOB Name DOB Name DOB CCLF-FC 006 (Rev. 11/00) POST SEPARATION SUPPORT AFFIDAVIT - Page1>>>> 2 A. Do you have primary physical custody of these children? rr Yes rr No B. Do you pay or receive support payments for these children? rr Yes rr No If yes, include the amount in Section VI. Current Monthly Income, below. If no, provide brief explanation below. II. PERSONAL INFORMATION Your Present Age Your Current Education Level Indicate any special training you have received below. III. WORK HISTORY List your work history below starting with your most current job. Explain periods of unemployment. Employment Dates Employer Name & Address Salary Job Description IV. CHILD CARE Provide childcare information for Children of the Parties in Section A, below. Name of Normal Daycare Center/ BabysitterAddress Average Monthly ExpenseA $ (Also include in Section VIII below)Provide childcare information for Children Not of the Parties in Section B, below. Name of Normal Daycare Center/ BabysitterAddress Average Monthly ExpenseB $ (Also include in Section VIII below) V. ASSETS List below a summary of all liquid assets in your control. Value of Stock, Bonds, etc. Saving Account Balance Value of all Remaining Liquid/Cash Assets$ $ $ CCLF-FC 006 (Rev. 11/00) POST SEPARATION SUPPORT AFFIDAVIT - Page2>>>> 3 VI. CURRENT MONTHLY INCOME Indicate below your current income on a calculated monthly average. AMOUNT1. EMPLOYMENT GROSS INCOME (Include commissions, bonuses, overtime, etc.) Hourly Salary Rate Average Number of Hours Worked Monthly $ $ 2. OTHER INCOME Column A Support Received (Parties Children) $ Support Received (Other Children) $ Retirement Income $ Disability Income $ AFDC $ Food Stamps $ (List) Other $ (List) Other $ 3. TOTAL OTHER INCOME (Total of Column 2-A above) $ TOTAL GROSS INCOME (Total of #1 and #3 above)$ 4. PAYROLL DEDUCTIONS Column A Federal Tax $ Social Security $ Medicare $ State Tax $ Health Insurance (Only by Payroll Deduction)$ Retirement $ (List) Other $ (List) Other $ 5. TOTAL PAYROLL DEDUCTIONS (Total of Column 4-A above) $ 6. CHILD SUPPORT PAID (Parties Children) $ 7. CHILD SUPPORT PAID (Other Children) $ TOTAL DEDUCTIONS (Total of #5, #6 and #7 above)$ TOTAL NET INCOME (Total Gross Income minus Total Deductions above)$ (Indicate under Section IX. Summary on Page 6 below.) 8. Have you experienced a recent increase or decrease in your income? rr Yes rr No9. Do you anticipate any change in your income in the near future? rr Yes rr No If you answered yes to #8 or #9 above, provide brief explanation below. CCLF-FC 006 (Rev. 11/00) POST SEPARATION SUPPORT AFFIDAVIT - Page3 >>>> 4 VII. CURRENT MONTHLY LIVING EXPENSES List below your CURRENT average monthly living expenses. Explain any recent or anticipated changes. Itemized Regular Monthly Living Expenses Self Children Total Rent or Mortgage Payment $ $ $ SHELTER Home Tax, Insurance, etc. $ $ $ Maintenance $ $ $ Electricity $ $ $ Heat (gas, oil) $ $ $ UTILITIES Sewer $ $ $ Trash $ $ $ Telephone $ $ $ At Home $ $ $ FOOD Away from Home $ $ $ School Meals for Children $ $ $ MEDICAL (Doctors, Dentist, Drugs, Hospital) $ $ $ Car Payment (For car you drive) $ $ $ Other Car Payment (Explain) $ $ $ Gas $ $ $ TRANSPORTATION Auto Repair, Maintenance $ $ $ Other costs (Bus, Taxi, etc.) $ $ $ Car Insurance $ $ $ OTHER INSURANCE Life Insurance $ $ $ (Not included in Section VI. #4 Medical Insurance $ $ $ Payroll Deductions on previous (List) Other page) $ $ $ GROOMING $ $ $ CLOTHING $ $ $ LAUNDRY & DRY CLEANING $ $ $ Cable Television $ $ $ Subscriptions $ $ $ Memberships RECREATION & $ $ $ ENTERTAINMENT Internet Access Fee $ $ $ (List) Other $ $ $ (List) Other $ $ $ For Yourself EDUCATION $ $ $ (Includes fees, books, etc.) For Your Children $ $ $ CHILD CARE (Daycare, Babysitting) $ $ $ GIFTS (YOU GIVE) $ $ $ Subtotal of Items Listed above $ $ $ (Continued on next Page) CCLF-FC 006 (Rev. 11/00) POST SEPARATION SUPPORT AFFIDAVIT - Page4 >>>> 5 Subtotal of Items From Previous Page $ $ $ (Continued on previous Page) Itemized Regular Monthly Living Expenses (Continued)Self Children TotalDONATIONS (YOU MAKE) $ $ $ OTHER (List) $ $ $ OTHER (List) $ $ $ OTHER (List) $ $ $ OTHER (List) $ $ $ OTHER (List) $ $ $ TOTAL EXPENSES $ $ $ TOTAL MONTHLY LIVING EXPENSES $ (Indicate under Section IX. Summary on Page 6 below.) VIII. DEBTS Itemize Marital Debts You Are Paying Balance At DOS Current Balance Monthly Payment $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Itemize Other Debts You Are Paying $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ TOTAL $ $ $ TOTAL MONTHLY DEBT PAYMENT $ (Indicate under Section IX. Summary on Page 6 below.) CCLF-FC 006 (Rev. 11/00) POST SEPARATION SUPPORT AFFIDAVIT - Page5 >>>> 6 IX. SUMMARY Column A Column BTOTAL NET INCOME (Section VI above) $ TOTAL MONTHLY LIVING EXPENSES (Section VII above) $ TOTAL MONTHLY DEBT PAYMENT (Section VIII above) $ TOTAL $ $ 1. If Column A Total is greater than Column B Total, enter difference here (+) $ 2. If Column B Total is greater than Column A Total, enter difference here () $ X. OTHER PARTYS FINANCES Provide a brief summary of any income other than Regular Payroll Income that you contend the opposing party receives. SWORN AFFIDAVIT I hereby certify that having been duly sworn upon my oath, do hereby depose and state that all information contained in this Post Separation Support Affidavit is true and accurate to the best of my information and belief. Date Signature of Party p Plaintif