COURT Employer Wage COUNTY .OF. . . . . . . . . . .Form .5 - . . . . . . . . . . . . . . .Affidavit.Page 1 of 2) ......... .. .... .. ....... . : In The General Court Of Justice Index No. STATE OF NORTH CAROLINA : Wayne County Lenoir County GreeneCounty District Court Division Family Calendar No. Court : JUDICIAL SUBPOENA File No. Plaintiff(s) Plaintiff: -against- : VERSUS EMPLOYER WAGE AFFIDAVIT : Defendant: : TO: The employer of . In order to verify the income of the above Defendant(s) : named employee,. you . . . requested.to.furnish. the. information .on this .form.for use in a court proceeding involving your . . . . . . . . . . are . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . employee. By your verifying this information, you may avoid having to appear in Court and testify as to the earnings of your employee. 1. Current gross monthly income: Please PEOPLEgrossTHE STATE OF NEW YORK formulae: THE compute OF monthly income using the following (if pay period is weekly, multiply weekly gross income by 4.3) (if pay period is every other week, multiply the gross income by 2.15) TO (if pay period is twice monthly, multiply the gross income by 2) (Gross Monthly Income) 2. Does the above gross income include income from overtime or bonuses? No Yes (if yes, specify the total amount and the average monthly amount.) GREETINGS: Explanation: Overtime: Avg. per mth: Bonuses: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Avg. per mth: , the Honorable at the Court located at County of 3. What is employee's current rate of pay? per in room , on the day of , 20 , at o'clock in the noon, and at any recessed 4. Total income for last calendar year. Gross: or adjourned date, to testify and give evidence as a witness in this action on the part of the Net: 5. Does the employee receive any benefits other than salary: (for example: use of a car or cell phone, etc.) No Yes (if yes, explain) Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a 6. Is the employee paid on commission? result of your failure to comply. No Yes (if yes specify monthly gross pay) (Average monthly gross from commissions) Witness, Honorable 7. How often is the employee paid? Court in Number of hours workingCounty, per day? , one of the Justices of the day of , 20 Number of days working per week? 8. What are the employee's deductions from gross pay per pay period? A. State: (Attorney must sign above and type name below) B. Federal: C. FICA: D. Medical Attorney(s) for Insurance: 9. A. If there is a deduction for medical insurance, how much of the medical insurance premium is allocated for coverage of children? B. Does the medical insurance include dental and/or other coverage? No Yes (If yes, what health care services are covered)? per Office and P.O. Address C. What are the terms of the deductible payments required under the medical coverage provided? Eighth Judicial District Family Court Form 5 3/01 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . .Form.5 . .Employer .Wage. Affidavit. Page 1 of 2) ......... .. .... . ........ .... ....... .. : 10. How many exemptions are claimed? Index No. 11. When is the last date the employee was paid? : Calendar No. 12. What pay increase, if any, has the employee received in the past twelve (12) months? Plaintiff(s) 13. What is the nature of the employee's work? -against- : JUDICIAL SUBPOENA : 14. What date did the employee start working for you? : 15. How long has the employee worked for you? (weeks, months, years). Attach the employee's W-2 Forms : for the time that he/she has worked for you up to and including the past three (3) years. 16. Is there any other information, concerning your employee's earnings, which you feel would be helpful to the Court Defendant(s) : ...................................................... THE PEOPLE OF THE STATE OF NEW YORK AFFIDAVIT The undesigned, after having been duly sworn, deposes and says: TO 1. I am the Personnel Officer, or the person in charge of the payroll records of (name company) GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before (Name of Plaintiff or Defendant) is an employee of the company , at the Court located at County of 3. That the room in information provided on this form concerning the earnings, deductions, company benefits, length of employment,recessed , on the day of , 20 , at o'clock in the noon, and at any and other information requested are true and give evidence as a witness in this action on the part of the and accurate to the best of my knowledge, inforamation, and belief. or adjourned date, to testify 2. That the Honorable named above. 4. That I have attached employee's W-2 Forms as requested in Number 15 above. Date Title Signature Of Affiant Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. SWORN AND SUBSCRIBED BEFORE ME THIS DATE Notary Public My Commission Expires Court Witness, Honorable in County, (Seal) , one of the Justices of the day of , 20 (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address Eighth Judicial District Family Court Form 5 3/01 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com