Form 30C-1(long form) NORTH CAROLINA IN THE GENERAL COURT OF JUSTICE COUNTY DISTRICT COURT DIVISION FILE NO AFFIDAVIT OF: Plaintiff Plaintiff Defendant vs. SEEKING SUPPORT Post Separation Alimony Child Support Defendant FROM WHOM SUPPORT IS SOUGHT Post Separation Alimony Child Support THE UNDERSIGNED, having been first duly sworn as to the truthfulness and completeness of this affidavit, deposes and says PART 1: EXPENSES AND NEEDS FOR CHILDREN AND/OR SELF A. Listed are the names and ages of the children currently residing with me or which may come to reside with me for which support is sought: Name Age Name Age Name Age Name Age Name Age Name Age B. The amounts listed as follows are the average monthly amounts of expense s and needs for my support and/or the support of our children who live with me now or who may come to live with me. (Do not include items deducted from your paycheck) INDIVIDUAL NEEDS & EXPENSES SELF CHILDREN TOTAL Food at home F ood away from home (school , work,etc) Clothing purchase Clothing laundry & dry cleaning Cosmetic, shampoo, personal care Tobacco and alcohol Medical insurance Dental Insurance Page 1 of 7 American LegalNet, Inc. www.USCourtForms.com>>>> 2Financial affidavit - form 30C INDIVIDUAL NEEDS & EXPENSES SELF CHILDREN TOTAL (Continued) Uninsured Doctor bills Uninsured appliances (e.g. glasses) Uninsured hospital bills Uninsured prescription drugs Uninsured over the counter drugs Uninsured dental bills Uninsured orthodontic bills Other uninsured expenses Child care day care Baby sitters Educational expenses tuition Educational expenses supplies & books Educational expenses insurance Educational expenses fees Educational expenses pictures Educational expenses lunches Haircuts Child support paid regularly Vacations Memberships Admissions (e.g. movies, sports, etc) Professional dues and licenses Childrens allowance Childrens activities and lessons Birthday gifts Christmas gifts Special gifts Other gifts Church donations Other donations Insurance: life, disability, accident Other: TOTAL Page 2 of 7 American LegalNet, Inc. www.USCourtForms.com>>>> 3Financial affidavit - form 30C A. FIXED MONTHLY EXPENSES SHELTER Rent House payment Taxes Insurance Other: TOTAL SHELTER UTILITIES Electricity Water and sewer Cable TV Heat Telephone Other TOTAL UTILITIES TRANSPORTATION Car payments Gasoline Maintenance and repairs Insurance Registration TOTAL TRANSPORTATION OTHER FIXED EXPENSES TOTAL OTHER FIXED EXPENSES Page 3 of 7 American LegalNet, Inc. www.USCourtForms.com>>>> 4Financial affidavit - form 30C GRAND TOTAL OF ALL FIXED MONTHLY EXPENSES $ D. Percentage of fixed expenses applied to children and self. Self % = $ Children % = $ E. Monthly Payments on Debts (not deducted from paycheck) Please list deb ts to Appliance or furniture stores; bank or credit cards; finance companies or any other i ndebtedness. DEBTS BALANCE DUE MONTHLY PAYMENT TOTAL MONTHLY DEBTS PART 2: INCOME A. I am paid weekly: every other week; twice monthly; monthly; other I have gross monthly income from all sources as follows: (NOTE: To arrive at monthly figures, weekly income is multiplied by 4.3; every other week is multiplied by 2.15 and twice monthly is multiplied by 2.) INCOME MONTHLY AMOUNT Wages Overtime Commissions Bonus Interest Dividends Trust fund Social Security Pension (or military retirement) Business profit Rents Child support & alimony Other: TOTAL GROSS INCOME Page 4 of 7 American LegalNet, Inc. www.USCourtForms.com>>>> 5Financial affidavit - form 30C B. I have regular itemized monthly deductions from gross income as follows: MONTHLY DEDUCTIONS MONTHLY AMOUNT Federal income taxes State income taxes Social Security Retirement Dental insurance Car payments United Way Medical insurance Life, disability, accident insurance Credit Union Debt payment Child support Other deductions: TOTAL C. My total net income (gross income less deductions) is $ D. I have ; have not ; received substantially the same income for the past 12 months. If not substantially the same, explain the reason for the change: E. For tax purposes, I claim exemptions on the W4 forms (including myself). F. That I do not have any income or employment other than that listed in this affi davit. G. That true and accurate copies of the latest personal State and Federal I ncome tax returns which I have filed are attached to this affidavit, together with a copy of my latest payroll stub or voucher. H. That true and accurate copies of all financial statements submitted by m e to any lending institution in the past two years are attached to this affidavit. I. That since the date of my separation from my spouse, I have provided support in the total sum of $ for my minor child(ren) living with my spouse and support in the sum of $ for my spouse. J. That my present place of employment is at . If not employed, my last regular job was at and I worked there until . Page 5 of 7 American LegalNet, Inc. www.USCourtForms.com>>>> 6Financial affidavit - form 30C PART 3: ADDITIONAL INCOME A. If your expenditures exceed your income, where did you receive the additional income to make up the difference? State the amounts, the dates and from whom you r eceived those funds AMOUNT DATE FROM WHOM RECEIVED PART 4: REAL ESTATE A. I own real estate individually with an approximate gross value of $ and with a mortgage balance of $ . B. My spouse and I own real estate together, having an approximate gross value of $ with a mortgage balance of $ . C. I own vehicles individually having an approximate gross value of $ , with an approximate debt remaining of $ . D. My spouse and I own vehicles having an approximate gross value of $ , with an approximate debt remaining of $ . E. I own other assets individually (including cash) totaling $ and I have other debts individually totaling $ . F. I own other assets with my spouse (including cash) totaling $ and we have other joint debts totaling $ . PART 5: SPOUSES EARNINGS To the best of my knowledge, information and belief, my spouse earns $ monthly. When I last knew exactly what my spouses income was, he or she earned $ monthly in (month), (year). Page 6 of 7 American LegalNet, Inc. www.USCourtForms.com>>>> 7Financial affidavit - form 30C PART 6: COMPLETENESS AND UNDERSTANDING I have read my answers to this affidavit and before signing it, I