1 Form #6 NORTH CAROLINA COUNTY OF HALIFAX Plaintiff: IN THE GENERAL COURT OF JUSTICE DISTRICT COURT DIVISION FILE NO. FINANCIAL AFFIDAVIT OF: PLAINTIFF DEFENDANT SEEKING SUPPORT: PSSU ALIMONY FROM WHOM SUPPORT IS SOUGHT: PLAINTIFF DEFENDANT VERSUS Defendant: Employer: Employer telephone: Employer Address: I am paid: weekly, other (explain) every other week, twice monthly, monthly, Last Taxable Year Adjusted Gross Income: Current Monthly Gross Income before Deductions: Current Monthly Take-home Pay after all Deductions: Detail of Monthly Gross Income Monthly Gross Wages: Investment income, interest, dividends: Bonus, commissions: Alimony received: Child Support received: Other (overtime, social security, disability, car allowance, shift pay, vacation/holiday pay): Date of Separation Current Mandatory Monthly Deductions Federal income tax: State income tax: Social Security taxes: Medicare taxes: Retirement: Garnishment: Other: Voluntary Monthly Deductions Health Insurance: Dental Insurance: Vision Insurance: Life Insurance: Disability Insurance: Medical Spending Account: Retirement: Other: Other: Date of Separation Current Date of Separation Current Halifax County Family Court Domestic Rules, Rev. 7/31/08 American LegalNet, Inc. www.FormsWorkFlow.com 2 Form #6 Part 1 Regular Recurring Monthly Expenses Date of Separation Date: Current Date: Expense Rent or Mortgage Payment Renters/Homeowners Insurance Taxes not included in mortgage Routine house & appliance repair/maintenance Electricity Gas, home heating fuel, oil Water Garbage Cable, digital television Telephone Internet service Yard maintenance Home security system House cleaning service Pest control services Automobile payment Auto insurance Gasoline (auto) Auto repair/maintenance, registration, taxes Food and household supplies Pets (insurance, vet, food, kennel) Other: GRAND TOTALS FOR PART 1: Halifax County Family Court Domestic Rules, Rev. 7/31/08 American LegalNet, Inc. www.FormsWorkFlow.com 3 Form #6 Part 2 Individual Monthly Expenses Date of Separation Date: Expense Medical Insurance premium Dental/Vision Insurance premium Uninsured Medical expenses (co-pays, deductibles) Uninsured Dental & Orthodontic expense Uninsured Prescription and OTC drugs & medication Other uninsured medical expenses (e.g. optical) Other insurance premiums (life, disability, etc.) Work-related child care expense, including summer camps Cellular/digital mobile telephone Eating Out School Lunches Newspapers, Magazines Clothing, accessories Personal Upkeep (barber, hair stylist) Laundry, Dry Cleaning Education (tuition, fees, supplies) Babysitting, child care, summer camp (not included above) Dues (professional, social, school) Extracurricular (piano, sports, dance, etc.) Church donations SUBTOTALS FOR PART 2 (this page) Self Children Total Date: Self Children Total Current Halifax County Family Court Domestic Rules, Rev. 7/31/08 American LegalNet, Inc. www.FormsWorkFlow.com 4 Form #6 PART 2 CONTINUED Date of Separation Date: Expense Other charitable contributions Entertainment & Recreation Club dues & assessments Allowances for Children Annual vacation Gifts (Holidays, birthdays) Child support for another child Spousal support for another spouse Professional fees (CPA, etc.) School Loans Retirement & investment Savings College Fund Other: Other: GRAND TOTALS FOR PART 2: Self Children Total Date: Self Children Total Current Halifax County Family Court Domestic Rules, Rev. 7/31/08 American LegalNet, Inc. www.FormsWorkFlow.com 5 Form #6 Part 3 - Debts Creditor Balance due on DOS Monthly Payment Current Balance due Monthly Payment GRAND TOTALS FOR PART 3: Verification I certify that aforementioned is true, complete, and accurate to the best of my ability. _____________________________ Affiant ____________________ County, North Carolina I certify that ____________________________ personally appeared before me this day, and acknowledged to me that he or she voluntarily signed the foregoing document for the purpose stated therein and in the capacity indicated. Date: ______________________ _________________________ (Signature) ______________________, Notary Public (Notary's printed name) My Commission Expires: ________________ Halifax County Family Court Domestic Rules, Rev. 7/31/08 American LegalNet, Inc. www.FormsWorkFlow.com 6 Form #6 CERTIFICATE OF SERVICE I hereby certify that a copy of this Financial Affidavit has been served in the following manner: By depositing a copy in the US Mail in a properly addressed, postpaid envelope to: By hand delivery to: Other: Date: ___________________________________________ Plaintiff Attorney for Plaintiff Defendant Attorney for Defendant Halifax County Family Court Domestic Rules, Rev. 7/31/08 American LegalNet, Inc. www.FormsWorkFlow.com