Form #7 NORTH CAROLINA HALIFAX COUNTY ASSIGNED JUDGE: ______________ IN THE GENERAL COURT OF JUSTICE DISTRICT COURT DIVISION FILE NO. _________________________ _____________________________, Plaintiff vs. _____________________________ , Defendant _____________________________, being duly sworn, deposes and says: (personnel officer) EMPLOYER WAGE AFFIDAVIT 1. That he/she is an employee of _____________________________________ (name of company) located in _______________________________; 2. That ___________________________ in the above entitled action is an (name of plaintiff or defendant) employee of said company; 3. That the records attached hereto of _______________________'s earnings, (plaintiff/defendant) deductions, company benefits and length of employment is true and correct to the best of affiant's information and belief. This the ____ day of __________________ , ______. ______________________________ Affiant (Personnel Officer) ______________________________ Title: Subscribed and sworn before me this the ____ day of ______________, _____. ____________________________________ Notary Public My Commission Expires: ________________ Halifax County Family Court Domestic Rules, Rev. 7/31/08 American LegalNet, Inc. www.FormsWorkFlow.com Form #7 EARNINGS INFORMATION 1. Earnings last calendar year, including bonus, if any: a) b) 2. Gross: Net: $___________ $___________ Present rate of pay: $______ per ________ (insert time period, ie. week, month, etc.) If employee is paid on production or commission, what is present average gross pay? $________ per _________ (insert time period, ie. week, month, etc). 3. 4. 5. 6. How often is employee paid? _______________________________________________________ Number of hours working per day? __________________________________________________ Number of days working per week? __________________________________________________ Deductions from gross pay per pay period: a) b) c) d) State taxes: Federal taxes: FICA: Medical Insurance* $__________ $__________ $__________ $__________ *How much of medical insurance premium is allocated for coverage of children? $___________ per _____________. *Does medical insurance include medical, dental and/or other coverage? If so, what health care services are covered? *What are the terms of the deductible payments required under the medical coverage provided? 7. 8. Number of exemptions claimed: ___________________ Date employee last paid: _________________________ How many pay periods, if any, are employee's earnings retained by employer? ______________ 9. Earnings this calendar year through date employee was last paid, including bonus, if any: a) b) Gross: Net: $___________ $____________ 10. Is employee paid a bonus? _______ If "yes" explain: a) b) c) d0 how bonus is computed: _________________________________ When bonus is paid: _____________________________________ Amount paid last calendar year: ____________________________ Amount paid this calendar year: ____________________________ 11. What pay increase, if any, has employee received in the past twelve months? Halifax County Family Court Domestic Rules, Rev. 7/31/08 American LegalNet, Inc. www.FormsWorkFlow.com Form #7 12. Nature of employment: 13. Date(s) of Hire/service: 14. Amount paid by employer on employee's behalf for: a) b) c) d) e) Medical Insurance: Disability Insurance: Dues: Retirement: Reimbursed Expenses $_______ per _______ $_______ per _______ $_______ per _______ $_______ per _______ $_______ per _______ Halifax County Family Court Domestic Rules, Rev. 7/31/08 American LegalNet, Inc. www.FormsWorkFlow.com