Financial Affidavit {Form 04}

FORM 4 NORTH CAROLINA IN THE GENERAL COURT OF JUSTICE th 28 JUDICIAL DISTRICT DISTRICT COURT DIVISION BUNCOMBE COUNTY FILE NO.____________ _____________________________ FINANCIAL AFFIDAVIT OF: Plaintiff DOB:________________ Plaintiff Defendant vs. PARTY SEEKING SUPPORT Post Separation Alimony ______________________________ Child Support * Defendant DOB: _______________ SUPPORT SOUGHT FROM Post Separation DATE OF MARRIAGE: _____________ Alimony DATE OF SEPARATION: ___________ Child Support * THE UNDERSIGNE, havingD been first duly sworn as to the truthfulness and completeness of this affidavit, deposes and says: 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 ________ * If this case is for Guideline Child support only, COMPLETE ONLY PART 1, sign and have notarized. PART 1: INCOME A. I am paid weekly: every other week; twice monthly; monthly; other I have gross monthly income from all sources as follows: INCOME MONTHLY AMOUNT Wages Overtime Commissions Bonus Interest Dividends Trust fund Social Security benefits Pension, Disability or Retirement income Business profit Rental Income Child support & alimony Other: TOTAL GROSS INCOME My present place of employment is at _______________________. If not employed, my last regular job was at _______________________ and I worked there until _________________. Page 1 of 5 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2I have ; have not ; received substantially the same income for the past 12 months. If not substantially the same, explain the reason for the change: ________________________________________________________________________ ______ ________________________________________________________________________ ______ ________________________________________________________________________ ______ Monthly costs for work related childcare costs $ _______________ Monthly costs for the childrens health insurance premiums $ _______________ My other pre-existing child support payments for other children are $ _______________ Monthly extraordinary expenses for the children, if any $ _______________ 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. 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). A copy of my latest payroll stub or voucher is attached hereto. ________________________________________________________________________ ______ STOP HERE IF THE ONLY ISS UE IN THIS CASE I S GUIDELI NE CHIL D SUPPORT PART 2: ADDITIONAL INCOME A. If your expenses listed in PAR T 3 (below) exceed your income, where did you receive the additional income to make up the difference? State the amounts, the dates and from whom you received those funds. AMOUNT DATE FR OM WHOM RECEIVED PART 4: REAL EST ATE AND OTE HRE ASSS ETS 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 $_____________. Page 2 of 5 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 3 PART 2: EXPENSE S FOR CHIL DRE N AND/OR SE L F A. The amounts listed as follows are the average monthly amounts of expenses, needs and anticipated expenses 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) ACTUA L/ANTICIPA TE D SE LF CHILDR EN NOTES INDIVIDUAL NEED S & EXPENS ES ACTUAL ANTICIP. ACTUAL ANTICIP. Food at home Food away from home (school , work, etc) Clothing purchase Clothing laundry & dry cleaning Cosmetic, shampoo, personal care Tobacco and alcohol Medical insurance Dental Insurance 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 INDIVIDUAL Page 3 of 5 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 4B. FIIXE D MONTHL Y EXPENSES SHELTE R ACTUA L ANTICIPATED NOTES Rent House payment Taxes Insurance Other: TOTAL SH EL TER UTIL ITIE S ACTUA L ANTICIPATED NOTES Electricity Water and sewer Cable TV Heat Telephone Other TOTAL UTILITIES TRANS PORTATION ACTUA L ANTICIPATED NOTES Car payments Gasoline Maintenance and repairs Insurance R egistration TOTAL TRANS PORTATION OTHER FIXED EXPENSES ACTUA L ANTICIPATED NOTES TOTAL OTHER FIXED EXPENSES TOTAL OF ALL F IXE D MONTHLY EXP ENSES $____________ PERCENTAGE OF FIXED EXPENSES APPL IED TO CHIL DREN AND SEL F: Self %_____________ = $__________________ Children %_____________ = $__________________ Page 4 of 5 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 5C. MONTHLY PAYMENTS ON DEBTS(not deducted f rom paycheck) Please list debts to bank or credit cards, stores, finance companies or any other indebtedness