STATE OF NORTH CAROLINA Montgomery County Moore County Randolph County Plaintiff: In The General Court of Justice District Court Division Family Court File No. -CVD- VERSUS Defendant: POST SEPARATION SUPPORT/ALIMONY FINANCIAL AFFIDAVIT The Undersigned Plaintiff Defendant, having been first duly sworn as to the truthfulness and completeness of thie Affidavit, deposes and says: My average monthly financial needs and my average monthly income, while living separate and apart from my spouse, are as follows: A. Individual Needs 1. Groceries & Household Goods 2. Food (School/Work lunches) 3. Clothing 4. Personal Care (includes laundry, dry cleaning, cosmetics, grooming) 5. Recreation/Entertainment 6. Activities (Sports, Clubs) 7. Medical & Dental Insurance (if NOT withheld from earnings) 8. Uninsured Medical & Dental Expenses 9. Child care 10. Educational expenses (includes school supplies) 11. Donations, dues & charity 12. Magazines, newspapers, books, etc. 13. Gifts-birthday, wedding, anniversaries, funeral 14. Car- gas and maintenance 15. Other: 16. Other: 17. Other 18. Other 19. Other 20. Other Self Child(ren) Total $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21. Total Individual Needs B. Fixed Expenses: How much do you allocate for: 22. Rent or house payment 23. Property Tax (excluded above) 24. Homeowner's or Renter's Insurance 25. Household maintenance and repair 26. Yard maintenance 27. Electricity 28. Water 29. Heat (gas, fuel, oil, etc.) 30. Telephone $0.00 Self $0.00 Child(ren) $0.00 Total $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Family Court Form 12/1/11 American LegalNet, Inc. www.FormsWorkFlow.com 31. Car payment 32. Car insurance 33. Other: 34. Other: 35. Other: 36. Other: 37. Other: $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38. Total Fixed Expenses C. Debt Payments (Itemize) To Whom Owed 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. $0.00 $0.00 Balance $0.00 Monthly Payments 51.Total Debt Payments 52. Total Individual Needs 53. Total Fixed Expenses 54. Total Debt Payments Self $0.00 $0.00 $0.00 $0.00 Child(ren) $0.00 $0.00 $0.00 Total $0.00 $0.00 $0.00 55. Total Monthly Needs D. Income 56. Wages 57. Overtime 58. Commissions 59. Bonuses 60. Interest 61. Dividends 62. Trust Fund 63. Social Security 64. Pension or Military Retirement 65. Business Profit 66. Federal Income Tax Refund (previous year divided by 12) 67. State Income Tax Refund (previous year divided by 12) 68. Other: 69. Other: 70. Other: $0.00 $0.00 Self $0.00 Total $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71. Gross Income Deductions: 72. Federal Income Tax (deducted from paycheck) 73. State Income Tax (deducted from paycheck) 74. FICA (deducted from paycheck) $0.00 Self $0.00 Total $0.00 $0.00 $0.00 Family Court Form 12/1/11 American LegalNet, Inc. www.FormsWorkFlow.com 75. Medical Insurance (deducted from paycheck) 76. Dental Insurance (deducted from paycheck) 77. Vision Insurance (deducted from paycheck) 78. Retirement (deducted from paycheck) 79. Federal Income Tax (not deducted from paycheck but directly paid to IRSprevious year divided by 12) 80. State Income Tax (not deducted from paycheck but directly paid to stateprevious year divided by 12) 81. Other: $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82. Total Deductions: 83. Net Income $0.00 $0.00 $0.00 $0.00 84. I am employed at 85. I have been employed there since __________________ (date). If not currently employed, my last regular job was at _______________________________________ and I worked there until ______________________ (date). 86. 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. ________________________________________________________ 87. I do do not have a second job. If you do have a second job: Employer: ____________________________________________________________________________________ Rate of pay: _________________________________ Total monthly income from second job: ________________ Attach: (1) Pay stubs (or other proof of income for previous 30 days) and (2) Most recent W-2 or 1099 form. Total Needs Self Total Needs Child(ren) Total Needs Self + Child(ren) Gross Income* Net Income* $0.00 $0.00 $0.00 $0.00 $0.00 Summary *Does not include figures regarding additional job. Signature of Affiant Plaintiff Defendant Date Notary Seal SWORN AND SUBSCRIBED BEFORE ME THIS DATE Notary Public My Commission Expires Family Court Form 12/1/11 American LegalNet, Inc. www.FormsWorkFlow.com