STATE OF NORTH CAROLINA IN THE GENERAL COURT OF JUSTICE COUNTY OF GUILFORD DISTRICT COURT DIVISION _______-CvD-_____________ AFFIDAVIT OF: (Name) ___________________________________, Plaintiff ___________________________________, Defendant _____ PLAINTIFF _____ DEFENDANT SEEKING THE FOLLOWING SUPPORT: _____ PSS/ALIMONY _____ CHILD SUP PORT FROM WHOM THE FOLLOWING IS SOUGHT: _____ PSS/ALIMONY _____ CHILD SUPPORT Number of minor children: _______ Other dependents in home: _______ The undersigned Affiant, having been first duly sworn as to the truthfulness and completeness of this affidavit, states that the average monthly financial needs for the support of the child(ren) in this case and the Affiant’s MONTHLY income and expenses are as follows: PART I: INCOME INFORMATION 1. My legal name is: 2. My Social Security Number 3. I am: First Job Second Job Self-employed doing: Employed by: Employer's address(es): Employer's telephone(s): I receive the following AVERAGE MONTHLY GROSS INCOME (based on 52/12 weeks or 26/12 biweekly periods per month) from the following sources: A. Wages/Salary $__________________________ E. Rent (net) B. Bonuses $____________________ $__________________________ F. Business profit (net) $____________________ C. Commissions $__________________________ G. Social Security D. Interest/Dividends/Investments $_____________ $____________________ H. Pension/Retirement $_____________________ 1 I. Other (itemize) $_____________________ TOTAL MONTHLY GROSS INCOME: $_____________ 1 “Other Income" includes (but is not limited to): severance pay, trust income, annuity income, capital gains, Workers Compensation benefits, Unemployment Insurance benefits, disability pay, insurance benefits, gifts, prizes and alimony and maintenance received from any person(s) not a party in this case. Appendix B, Form1B, p.6 (Rev.07/02) 1 American LegalNet, Inc. www.USCourtForms.com PART II - CHILD SUPPORT INFORMATION 1. I have the following average MONTHLY expenses: A. Court-ordered or Separation Agreement-required child support for my children not living with me (and not part of this action): Name(s) of children: $___________________ B. Responsibility for my other children who live with me (and not part of this action)(calculated per Guidelines): Name(s) and age(s) of other child(ren): $___________________ C. Gross monthly income of other responsible parent (in other case): Monthly work-related child care costs (in this case)(100%) Child(ren)’s portion of my health insurance cost: $___________________ Extraordinary expenses for child(ren) (itemize) (As defined on Page 4 of the Guidelines) $___________________ D. E. F. 2. Number of nights the child(ren) spend with me each year $___________________ $___________________ _____ The following documentation rules apply to all child support, post-separation support, and alimony cases. As required by the Civil Case Management Rules, I hereby furnish the opposing party (but not the court)by attachment hereto: (a) For the last four (4) months, proof of all my income, including, but not limited to, copies of all pay stubs, pay and expense vouchers, employee benefit statements, stock option statements, company financial statements and tax returns and/or Form 1040, Schedule "C" (if I am self-employed or employed by a closely-held corporation). (b) For the last three (3) months, statements showing all accounts in banks, credit unions, brokerage accounts, and all other financial institutions for which I have been an authorized signer. (c) A listing of all outstanding debts with written documentation or account statements for each creditor showing the principal balance I now owe and the terms of payment. (d) For the last two (2) years, all federal tax returns filed by me or for me, including all schedules and attachments (Forms W-2, 1099, etc.) together with all year-end tax documentation (Forms W-2, 1098, 1099, Requests for Extension, etc.) for the most recent tax year, if that return has not yet been filed. (e) For the last two (2) years, all personal financial statements I gave to anyone, anywhere. I understand that my failure to produce all the above documents to my opponent without just cause may subject me to sanctions (including attorney's fees and costs) in the discretion of the presiding judge. Appendix B, Form1B, p.6 (Rev.07/02) 2 American LegalNet, Inc. www.USCourtForms.com PART III POSTSEPARATION SUPPORT, ALIMONY, AND NON-GUIDELINES CHILD SUPPORT CASES NOTE: To convert weekly income to monthly, multiply by 52/12; to convert biweekly income to monthly, multiply by 26/12. A. NET INCOME My total MONTHLY GROSS INCOME (from Part I) is: I have the following average monthly deductions from my gross income: Federal income taxes Medical insurance State income taxes Life insurance Social Security (FICA) Medicare ____________ Other ____________ Retirement/401-K TOTAL DEDUCTIONS: My average MONTHLY NET INCOME is: B. NEEDS AND EXPENSES I have the following average monthly needs and expenses (1) SHARED FAMILY EXPENSE House payment/rent Telephone(s)/Pager (incl. property tax and insurance) Electricity Home food & supplies Heat (gas, etc.) House maintenance Water Yard maintenance Cable TV Car payment Garbage Gasoline SUBTOTAL: I pro-rated the foregoing sub-total of family expenses between the child(ren) and myself as follows: Total amount for self: Total amount for child(ren): Reason(s) for method of pro-rating: Appendix B, Form1B, p.6 (Rev.07/02) 3 American LegalNet, Inc. www.USCourtForms.com (2) INDIVIDUAL EXPENSES Children Self (for whom I am legally Item Notes responsible) Religious Contributions Charitable Contributions School/work lunches Medical insurance (if not withheld from earnings) Uninsured medical/dental Uninsured prescription drugs Uninsured therapy (Explain if time limited) Clothing Grooming (hair, etc.) Laundry/dry cleaning Child care (work-related) Child care (other) Education (indicate nature in notes column) Allowances Activities (Y, sports, clubs) Entertainment/Recreation Meals out Christmas gifts Birthday gifts Subscriptions (newspapers, magazines, etc.) Life insurance Car insurance Car - other (registration, etc.) Other insurance (disability, etc.) Vacations Pets Other (itemize): SUBTOTAL: Appendix B, Form1B, p.6 (Rev.07/02) 4 American LegalNet, Inc. www.USCourtForms.com (3) SUMMARY OF EXPENSES Self Children Family - Pro-rated - from Section (1) ___________________ ___________________ Individual - from Section (2) ___________________ ___________________ TOTALS: ___________________ ___________________ C. DEBT PAYMENTS Debt Monthly Payment Balance Mortgage loan ___________________ ___________________ Car payment ___________________ ___________________ Cash reserve ___________________ ___________________ Credit cards (itemize): ___________________ ___________________ ___________________ ___________________ ___________________ __________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ TOTALS: ___________________ ___________________ STATE OF NORTH CAROLINA COUNTY OF GUILFORD VERIFICATION Being first duly sworn, I depose and say that I have read the preceding pages, and that I know the contents thereof; that the contents are true to my knowledge, except as to those matters and things stated upon information and belief, and as to those matters and things, I believe them to be true. Sworn to and subscribed before me this ____ day of ___________, 20____. A Notary Public of North Carolina My commission expires: Appendix B, Form1B, p.6 (Rev.07/02) __________________________ Affiant’s Signature (seal) 5 American LegalNet, Inc. www.USCourtForms.com 25.1 PULL APART AND SUBMIT ONLY PARTS I & II (PAGES 1 & 2) AND THIS PAGE IN GUIDELINES-ONLY CASES. SUBMIT ALL PAGES IN ALL POSTSEPARATION SUPPORT, ALIMONY and/or NON- GUIDELINES CASES GUIDELINES FOR THE USE OF THE AFFIDAVIT OF FINANCIAL STANDING PURPOSE: To establish a uniform procedure for the use of financial affidavits in child support, post-separation support, and alimony cases. SCOPE: The affidavit shall be used in cases involving the establishment and modification of private child support, post-separation support, and alimony. The term "support" refers to all of these actions. The term "party" means the plaintiff or defendant or either attorney. MANDATORY USE OF FINANCIAL AFFIDAVIT: Each party who seeks support or from whom support is sought shall file with the Clerk and serve upon the other party a Financial Affidavit of Financial Standing: using Form 1A when the income of the parties is from wages and the assets are fairly simple; using this form (Form 1B) when income, assets and expenses are more diverse. The moving party shall attach the Affidavit to his or her pleading. The responding party shall file and serve the Affidavit on the opposing party: within seven (7) days and no later than Friday preceding the Session Calendar Call in a Child Support case; within fourteen (14) days but no later than the Wednesday preceding the first week of the domestic term in which the case is scheduled for hearing in Post-Separation Support, Alimony and Non-Guidelines Child Support cases. MANDATORY FORM: The Affidavit of Financial Standing filed by a party shall not deviate from the form attached hereto, but parties may supplement the Affidavit by attaching additional financial information and/or documents. Appendix B, Form1B, p.6 (Rev.07/02) 6 American LegalNet, Inc. www.USCourtForms.com