Form #4 State of North Carolina Halifax County Plaintiff: Versus Defendant: In the General Court of Justice District Court Division File No.: Child Support Financial Affidavit The undersigned Plaintiff Defendant, having been first duly sworn as to the truthfulness and completeness of this Affidavit, deposes and says that my average gross income is as follows. 1. My Monthly Gross Income is: *I have attached a copy of my pay stub showing year-to-date data (gross and net income) and my last W2. 2. I have pre-existing Child Support Payments of: 3. My responsibility for Other Children is: 4. Directions: Add lines 2 and 3 5. Directions: Enter the amount on line 1 here 6. Directions: Enter the amount on line 4 here 7. Monthly Adjusted Gross Income Directions: Subtract line 6 from line 5 and enter here 8. My work-related child care costs for the children at issue in this case are (Attached to the form are the costs set forth herein.): 9. My health insurance premium costs for the children at issue in this case are (Attached to the form are the costs set forth herein): 10. I have the following extraordinary child-related expenses: A. B. C. Date: Signature of Affiant: Plaintiff Defendant SWORN AND SUBSCRIBED BEFORE ME THIS DATE Notary Public (Please print and sign name): __________________ (Print My Commission Expires: ________________________ (Sign) (SEAL) Halifax County Family Court Domestic Rules, Rev. 7/31/08 American LegalNet, Inc. www.FormsWorkFlow.com