INSTRUCTIONS TO COMPLETE EMPLOYER AFFIDAVIT OF INCOME AND BENEFITS 1. The Employer Affidavit of Income and Benefits is for the purpose of providing the court with information and records concerning a party’s income and employee benefits to assist the court in making decisions relative to financial aspects of the party’s case now pending. 2. If you are the custodian of records for your employer and you or your employer have been served with a subpoena commanding you or the employer to appear in court for the sole purpose of producing records in the possession and control of the employer, you may, in lieu of a personal appearance, tender to the Court by registered mail, certified copies of the records requested together with an affidavit by the custodian as to the authentication of the records tendered, or, if no such records are in the employer’s custody, an affidavit to that effect. 3. Please complete the attached employer affidavit if you are the person who is the designated custodian of records for the employer from whom the records have been subpoenaed. 4. Copies of the records are deemed “certified” if they are appended to the affidavit attached to these instructions and referred to therein. 5. If you have any of the following records in your possession and control, they should be identified in and appended to the Employer Affidavit: (a) Three (3) years worth of income information through the date of production should be produced. The meaning of the word “income” is as defined by the Internal Revenue Service and includes bonuses and commissions; (b) For the last full year prior to production of records, all records pertaining to any voluntary or involuntary deductions by the employer or employee as well as monthly records for the year in which the request for production is made if not a full calendar year; (c) For the last full year prior to production of records, all records pertaining to any employee benefits, including but not limited to health insurance (including medical, dental and other health care related), retirement benefits including employer matching, deferred compensation, stock options, life or disability insurance, car lease and expense reimbursement, cell phone or computer use or lease paid, frequent flyer miles, vacation, sick leave, paid leave, country club, health club or other memberships or dues. (d) Copies of any retirement plan and health care plan including family and dependent coverage in effect for the employee. Copies of any employment agreement or stock option agreement or non-compete agreement. (e) Inclusive dates of employment for any consecutive and non consecutive periods for the last five years (OVER) WAKE-DOM-12 (Rev. 10/02) (PAGE 1OF 3) American LegalNet, Inc. www.USCourtForms.com NORTH CAROLINA WAKE COUNTY IN THE GENERAL COURT OF JUSTICE DISTRICT COURT DIVISION FILE NO. ________________ _________________________________, Plaintiff, AFFIDAVIT v. (Employer Wage Affidavit ________________________________, Defendant. I, ____________________________ , (please print name) a Personnel Officer, being duly sworn, deposes and says: 1. I am employee of _______________________________ [name of company] located at _____________________________________________ [provide full address]; and 2. That _______________________________ , the [ ] Plaintiff, or [ ] Defendant in the above entitled action, is an employee of said company; and 3. That the records attached hereto of [ ] Plaintiff's, or [ ] Defendant's earnings, deductions, company benefits, and length of employment are true and correct to the best of affiant's information and belief. 4. That my work telephone number is ________________________________ . This the _______ day of _____________________________ , 20__ . _____________________________ Affiant (Personnel Officer) _________________________ Title Subscribed and sworn before me this the day of , . _________________________________ Notary Public My commission expires: ________________ WAKE-DOM-12 (Rev. 10/02) (PAGE 2OF 3) American LegalNet, Inc. www.USCourtForms.com EARNINGS INFORMATION . 2. . 4. . 6. Earnings last calendar year, including bonus, if any: a. Gross: $___________________________ b. Net: $___________________________ Present rate of pay: $ ___________ per ______________ [insert time period, i.e., week, month, etc.] *If Employee is paid on production or commission, what is present average gross pay? $ _____________ per ________________ [insert time period, i.e., week, month, etc.] 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. State Taxes: $ __________________________ b. Federal taxes: $ __________________________ c. FICA: $ __________________________ d. Medical Insurance: $ __________________________ i. How much of medical insurance premium is allocated for coverage of children? $ . ii. Does medical insurance include medical, dental and/or other coverage? If so, what health care services are covered? ______________ iii. What are the terms of the deductible payments required under the medical coverage provided? ______________ 7. Number of exemptions claimed: ___________________________ 8. Date employee last paid:_________________________________ 9. How many pay periods, if any, are employee's earnings retained by employer?_____ 10. Earnings this calendar year through date employee was last paid, including bonus, if any: a. Gross: $ ________________________________ b. Net: $ __________________________________ 1. Is employee paid a bonus? _______________ (yes or no) If yes, explain: a. How bonus is computed: ___________________________ b. When bonus is paid: ______________________________ c. Amount paid last calendar year: _____________________ d. Amount paid this calendar year: _____________________ 1. What pay increase, if any, has employee received in the past twelve months? 2. Nature of employment: ___________________________ 3. Date(s) of Hire/service: ___________________________ 4. Amount paid by employer on employee's behalf for: a. Medical Insurance: $ per b. Disability Insurance: $ per c. Dues: $ per d. Retirement: $ per e. Reimbursed expenses: $ per per WAKE-DOM-12 (Rev. 10/02) (PAGE 3OF 3) American LegalNet, Inc. www.USCourtForms.com