Free State of Wyoming - Wyoming


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Date: September 29, 2006
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State: Wyoming
Category: Court Forms - State
Author: Jacqueline Brown Zaddach
Word Count: 1,422 Words, 10,844 Characters
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STATE OF WYOMING

) )ss COUNTY OF_____________ ) _____________________________,

IN THE DISTRICT COURT ___________ JUDICIAL DISTRICT

) Civil Action No. _____________ ) Petitioner, ) ) vs. ) ) ____________________________, ) ) Respondent. ) _______________________________________________________________________________ CONFIDENTIAL FINANCIAL AFFIDAVIT W.S. §20-2-308 _______________________________________________________________________________ A financial affidavit must be completed by each parent. You must attach copies of your tax returns and W-2 forms for the most recent two years and by a copy of a cumulative earning statement for the current year. Parents who are self-employed must supply verified income and expense statements from their business for the two most recent years.

All financial affidavits and records required by law to be attached to the affidavit shall constitute a confidential file and are subject to inspection by persons other than the parties, their attorneys or the department of family services to the extent necessary to enforce the Child Support Enforcement Act and the Uniform Interstate Family Support Act only by court order. (Wyo. Stat. § 20-2-308(d)) THE UNDERSIGNED, (Print Name) _________________, hereby swears or affirms,

under penalty of perjury, that the following answers are correct and complete. PERSONAL INFORMATION 1. Your name: (First, Middle, Last) ______________________________________________ Gender: Male Female

CSMod 5 Confidential Financial Affidavit Approved by the Wyoming Supreme Court February 15, 2005 Page 1 of 8

2.

(a)

Your present address: _________________________________________________ City, State, Zip Code: _________________________________________________ Your home phone number: ( A message phone number: ( ) )

How long have you resided at this location? ________________________________ (b) If your mailing address is different than the above address, please provide your mailing address: ___________________________________________________________________ 3. 4. Your Social Security Number is: ______________________________________________ Check all that apply: Employed Self-Employed Both Unemployed

Parents who are self-employed must supply verified income and expense statements from their business for the last two years. 5. (a) (b) Your present employer: ________________________________________________ Employer's address: __________________________________________________ City, State, Zip Code: _________________________________________________ Employer's phone: ___________________________________________________ (c) 6. Your occupation: _____________________________________________________

Your work experience for the last three years is as follows: COMPANY AND DATES FROM - TO LOCATION JOB DESCRIPTION/ TITLE SALARY OR WAGE REASON YOU LEFT

7.

(a)

Your education is: ________years high school; _________years college; ________ years trade school; _______ years other _______________________.

(b)

List your degree(s) or certificate(s) in __________________________________ .

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8.

List the children you are legally responsible for supporting and who live with you:
COURT AND DATE OF ORDER

Child's Name

Birth Date

Social Security No.

SUPPORT/ MONTH

ARREARS (Amount Past Due)

9.

List any court-ordered support obligation for children who do not live with you:
COURT AND DATE OF ORDER

Child's Name

Birth Date

Social Security No.

SUPPORT/ MONTH

ARREARS (Amount Past Due)

10.

If you are the parent of any children not named above, list them below:
Social Security Child's Name Birth Date No. COURT AND DATE OF ORDER SUPPORT/ MONTH ARREARS (Amount Past Due)

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11. If you contribute to the support of any children for whom you have no legal obligation, list below:
OTHER PARENT'S NAME AND ADDRESS

Child's Name

Birth Date

Social Security No.

Does this child live with you?

YOUR RELATIONSHIP TO THE CHILD

Yes Yes Yes

No No No

12.

List all child(ren) involved in this civil matter:
Child's Name Birth Date Social Security No. Does this child live with you?

Yes Yes Yes Yes Yes

No No No No No

13.

Do you owe back child support (arrears) in this case? If so, how much? $____________.

14. Do you owe back child support (arrears) on any other child support obligations? If so, how much? (List total of all support arrearages for all children, except this case). $_____________. 15. Means tested benefits (POWER Program, Health Care Benefits under Title XIX of the

Social Security Act or similar state program, General Assistance, Food Stamps, Supplemental Security Income, etc.) are being provided to your children, as follows:
CHILD'S NAME BIRTH DATE STATE TYPE OF BENEFIT AMOUNT OF BENEFIT

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INCOME & EXPENSE INFORMATION 16. (a) List pay dates or otherwise describe pay schedule: weekly every two weeks twice per month (i.e. 1st and 15th of every month) monthly annually

. My gross income** (before deductions) is: $_____________ per month. (Convert annual, bimonthly, and weekly amounts to monthly amounts).
** Gross income (includes tips, commission and bonuses. Monthly amounts are calculated by multiplying weekly amount by 52 and dividing by 12; multiplying bi-weekly amounts by 26 and dividing by 12; and multiplying semi-monthly amounts by 24 and dividing by 12.

(b)

Please list the deductions taken out of your check by your employer: (Please provide copies of pay-stubs for all payroll deductions)
Voluntary Deductions, Continued Health, Dental, Vision Insurance Dues Bonds Stock Purchase Plan Flex Benefit Cafeteria Plan Disability Insurance Life Insurance Charity Child Care Other Other Total Monthly Deductions: Total Monthly Net Income*** $ $

Mandatory Deductions Federal Income Tax Social Security Tax Medicare Tax Current child support for other children Retirement/Pension deductions (mandatory deductions only) Other Other Voluntary Deductions Bank/Credit Union (savings) Bank/Credit Union (loan) Retirement/Deferred Compensation Filing Status: ____________ No. of Dependents Claimed: ____________

*** Net income means gross income less personal income taxes, social security deductions, cost of dependent
health care coverage for all dependent children, actual payments being made under preexisting support order for current support of other children, other court-ordered support obligations currently being paid and mandatory pension deductions. Payments towards child support arrearage shall not be deducted to arrive at net income.

(c) How many hours do you work each week? Regular _____ Overtime_____ Total __________
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Is the overtime listed above expected to continue on a consistent basis?

YES

NO

How often do you receive overtime compensation?_________________________________ (d) 17. Date of your last salary increase or decrease:_______________________________.

YOUR INCOME FROM ALL OTHER SOURCES (Include the monthly average of

annual or sporadic income; also include any government benefits): AMOUNT INCOME SOURCE ADDRESS OF SOURCE

18.

Has anyone been ordered to provide health insurance, or is there any other medical

provision in an existing court order? Check one: YES NO

If yes, explain: _____________________________________________________________ _________________________________________________________________________ 19. Are the child(ren) involved in this case covered by health insurance? Check one: YES NO

If yes, list the children covered below: _____________________ _____________________ _____________________ _____________________

____________________ ____________________

You must provide current written proof from your insurance carrier verifying the names of the actual person(s) covered under your policy. 20. Attached to this affidavit are: 1) copies of my last two years income tax returns, 2) copies of my W-2 Forms for the last two years, and

CSMod 5 Confidential Financial Affidavit Approved by the Wyoming Supreme Court February 15, 2005 Page 6 of 8

3) copies of statements of earnings from each of my employers showing cumulative pay for this year. Parents who are self-employed must supply verified income and expense statements from their business for the two most recent years.

PERJURY STATUTE 21. Wyoming Statute § 6-5-301, (1977, as amended) [Perjury] provides: (a) A person commits perjury if, while under a lawfully administered oath or affirmation, he knowingly testifies falsely or makes a false affidavit, certificate, declaration, deposition or statement, in a judicial, legislative or administrative proceeding in which an oath or affirmation may be required by law, touching a matter material to a point in question. (b) Perjury is a felony punishable by imprisonment for not more than five (5) years, a fine of not more than five thousand dollars ($5,000.00), or both.
OATH

I have read and understand the provisions of the above perjury statute. I affirm that this Confidential Financial Affidavit (including attachments) contains a complete disclosure of my income from all sources and that the representations made herein concerning my income are accurate to the best of my knowledge. I am aware that the court may punish as perjury any materially false statements knowingly made with intent to defraud or mislead. DATED this _____ day of ________________, 20___. ______________________________ Your Signature
(Sign only in front of Notary or Court Clerk.)

JURAT STATE OF _____________ ) ) ss. COUNTY OF ___________ ) Subscribed and sworn to before me on this _____ day of ________________20____, by ________________________________. WITNESS my hand and official seal. ______________________________ Notary Public / Court Clerk My Commissions Expires: ___________________
CSMod 5 Confidential Financial Affidavit Approved by the Wyoming Supreme Court February 15, 2005 Page 7 of 8

CERTIFICATE OF SERVICE I certify that on (date) the original of this document was

filed with the Clerk of District Court; and, a true and accurate copy of this document was served on the other party by OR Hand Delivery OR Faxed to this number

by placing it in the United States mail, postage pre-paid, and addressed to the following:

TO: ______________________________________ ______________________________________ ______________________________________

(Your signature)

Print name

CSMod 5 Confidential Financial Affidavit Approved by the Wyoming Supreme Court February 15, 2005 Page 8 of 8