Employment Information Affidavit {A And B}

NORTH CAROLINA ___________________ COUNTY IN THE GENERAL COURT OF JUSTICE DISTRICT COURT DIVISION ____ -CVD- ____________ ________________________, ) ) Plaintiff, ) ) v. ) ) ________________________, ) ) Defendant. ) ______________________________) AFFIDAVIT _________________________________ (personnel officer), being first duly sworn, deposes and says: That he/she is an employee of ____________________________________________ located in ____________________________________________________________; that ___________________________ ,_______________________________ in the above entitled action, is an employee of said company; that the record attached hereto of ____________________'s earnings, deductions, company benefits and length of employment is true and correct to the best of affiant's information and belief. This the _____ day of __________________________, _______. _______________________________ Affiant (personnel officer) _______________________________ Title: Subscribed and sworn to before me this the _____ day of ____________________, ________. ___________________________________ Notary Public My commission expires: ___________________ Form "A" American LegalNet, Inc. www.FormsWorkFlow.com EARNINGS INFORMATION 1. Earnings last calendar year, including bonus, if any: a) b) 2. gross: net: $________________ $________________ Present rate of pay: $__________________ per _____________________. If paid on production or commission, what is present average gross pay? $_______________Per ____________________. 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 *: $ ______________________ * How much of medical insurance premium is allocated for coverage of children? $ ____________________ per _________________________. 3. 4. 5. 6. 7. 8. Number of exemptions claimed: _____________________________________ Date employee last paid: _________________________________________ How many pay periods, if any, are employee's earnings retained by employer? ______________________________________________________________ Earnings this calendar year through date employee last paid, including bonus, if any: a) gross: $ _____________________ b) net: $ _____________________ Is employee paid a bonus? ________________________ If "yes" explain: a) How computed: _________________________________________ b) When paid: _____________________________________________ c) Amount paid last calendar year: ____________________________ d) Amount paid this calendar year: ____________________________ 9. 10. Form "B" American LegalNet, Inc. www.FormsWorkFlow.com 11. What pay increase, if any, has employee received in past twelve (12) months? Increase amount(s): _________________________________________ Date(s) received: __________________________________________ 12. 13. 14. Nature of employment: ______________________________________ Date of hire: _______________________________________________ Amount paid by employer on employee's behalf for: a) b) c) d) e) Medical insurance Disability insurance: Dues: Retirement: Reimbursed Expenses: $ ______________per ______________. $ ______________per ______________. $ ______________per ______________. $ ______________per ______________. $ ______________per ______________. 15. Amount of overtime employee worked in the past twelve (12) months. ________________________________________________________________ Amount of overtime that was available to employee in the past twelve (12) months. __________________________________________________________________ __________________________________________________________________ Please describe changes employee should expect, if any, within three months in job description, compensation and/or working hours: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ If not previously described herein, please describe changes, if any, employee has had within past three months in job description, compensation and/or working hours: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 16. 17. 18. American LegalNet, Inc. www.FormsWorkFlow.com