Affidavit (Appendix B) {1B}

ST ATE OF NORTH CAROLINA IN THE GENERAL COURT OF JUSTICE COUNTY OF GUILFORD DISTRICT COURT DIVISION _______-CvD-_____________ AFFIDAVIT OF: ___________________________________, (Name) Plaintiff ___________________________________, _____ PLAINTIFF Defendant _____ DEFENDANT SEEKING THE FOLLOWING SUPPORT: _____ PSS/ALIMONY _____ CHILD SUP POR T FROM WHOM THE FOLLO WING IS SOUGHT: _____ PSS/ALIMONY _____ CHILD SUPPO R T Number of minor children: _______ Other dependents in home: _______ The undersigned Affiant, having been firs t duly sworn as to the truthfulness and completeness of this affidavit, states that the average monthly financial needs for the support of the child(ren) in this case and the Affiants MONTHLY income and expenses are as follows : PART I: INCO M E INFORMATIO N 1. My legal name is: 2. My Social Security Number 3. I am: First Job Second Job Self-employed doing: Employed by: Employers address(es): Employers telephone(s): I receive the following AVER AGE MONTHLY GROSS IN COME (based on 52/12 weeks or 26/12 bi- weekly periods per month) from the following sources: A. Wages/Salary $__________________________ E. Rent (net) $____________________ B. Bonuse s $__________________________ F. Business profit (net) $____________________ C. Commissions $__________________________ G. Social Security $____________________ D. Interest/Dividends/Investments $_____________ H. Pension/Retirement $_____________________ 1 I. Other (itemize) $_____________________ TOTAL MONTHLY GR OSS INCOME: $_____________ 1 Other Income" includes (but is not limited to): severance pay, trust income, annuity income, capital gains, Workers Compensation benefits, Unemployment Insurance benefits, disability pay, insurance benefits, gifts, prizes and alimony and maintenance received from any person(s) not a party in this case. Appendix B, Form1B, p.6 (Rev.07/02) 1 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2 PART II - CHILD SUPPORT INFORMATION 1. I have the following average MONTHL Y expenses: A. Court-ordered or Separation Agreement-required $___________________ child support for my children not living with me (and not part of this action): Name(s) of children: B. Responsibility for my other children who live with $___________________ me (and not part of this action)(calculated per Guidelines): Na me(s ) and age(s) of other child(ren): C. Gross monthly income of other responsible parent $___________________ (in other ca se): D. Monthly work-related child care costs (in this $___________________ case)(100% ) E. Child(ren)s portion of my health insura nce cost: $___________________ F. Extraordinary expenses for child(ren) (itemize) $___________________ (As defined on Pag e 4 of the Guidelines) 2. Number of nights the child(ren) spend with me each year _____ The following documentation rules apply to all child support, post-s eparation support, and alimony case s. As required by the Civil Case Management Rules, I hereby furnish the opposing party (but not the court)by attachment hereto: (a) For the last four (4) months, proof of all my income, including, but not limited to, copies of all pay stubs, pay and expense vouchers, employee benefit statements, stock option statements, company financial statements and tax returns and/or Form 1040, S chedule "C" (if I am s elf-employed or employed by a closely-held corporation). (b) For the last three (3) months , statements showing all accounts in banks, credit unions, brokerage accounts, and all other financial institutions for which I have been an authorized signer. (c) A listing of all outstanding debts with written documentation or account statements for each creditor showing the principal balance I now owe and the terms of payment. (d) For the last two (2) years, all federal tax returns filed by me or for me, including all schedules and attachments (Forms W-2, 1099, etc.) together with all year-end tax documentation (Forms W-2, 1098, 1099, Requests for Extension, etc.) for the most recent tax year, if that return has not yet been filed. (e) For the last two (2) years, all personal financial statements I gave to anyone, anywhere. I understand that my failure to produce all the above documents to my opponent without just cause may subject me to sanctions (including attorneys fees and costs) in the discretion of the pres iding judge. Appendix B, Form1B, p.6 (Rev.07/02) 2 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 3 PAR T III POSTSEP AR ATION SU PPOR T, ALIMONY, AND NON-GUIDELI NES CHIL D SUPPOR T CAS E S NOTE: To convert weekly income to monthly, multiply by 52/12; to convert biweekly income to monthly, multiply by 26/12. A. NET INCOME My total MONTHLY GR OS S INCOME (from Part I) is: I have the following average monthly deductions from my gross income: Federal income taxes Medical insurance St ate income taxes Life insurance Social S ecurity (FICA) Retirement/401-K Medicare ____________ Other ____________ TOTAL DEDUCTIONS: My average MONTHLY NET INCOME is: B. NEED S AND EXPEN SES I have the following average monthly needs and expense s (1) SHARED FAMI LY EXPENSE House payment/rent Telephone(s)/Pager (incl. property tax and insurance) Electricity Home food & supplies Heat (gas, etc.) House maintenance Water Ya rd maintena nce Cable TV Ca r payment Garbage Gasoline SUBT OTAL: I pro-rated the foregoing sub-total of family expenses between the child(ren) and myself as follows: Total amount for self: Total amount for child(ren): Reason(s) for metho d of pro-rating: Appendix B, Form1B, p.6 (Rev.07/02) 3 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 4 (2) INDIVIDUAL EXPEN SES Children Item S elf (for whom I am legally Notes responsible) Religious Contributions Charitable Contributions School/work lunches Medical insurance (if not withheld from earnings) Uninsured medical/dental Uninsured prescription drugs Uninsured therapy (Explain if time limited) Clothing Grooming (hair, etc.) Laundry/dry cleaning Child care (work-related) Child care (other) Education (indicate nature in notes column) Allowances Activities (Y, sports, clubs) Entertainment/R ecreation Meals out Christmas gifts Birthday gifts Subscriptions (newspapers, magazines, etc.) Life insurance Car insurance Car - other (registration, etc.) Other insurance (disability, etc.) Vacations Pets Other (itemize): SUB TOTAL: Appendix B, Form1B, p.6 (Rev.07/02) 4 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<*******