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STATE OF NORTH CAROLINA COUNTY OF CABARRUS

IN THE GENERAL COURT OF JUSTICE DISTRICT COURT DIVISION FILE NO.

Plaintiff, v. Defendant. FINANCIAL AFFIDAVIT
[ ] PLAINTIFF [ ] DEFENDANT

INCOME INFORMATION Employer:_________________________________ Employer Telephone: _______________ Employer Address: _______________________________ Social Security No:__________________

Last Taxable Year Adjusted Gross Income: Monthly Gross Before Deductions: Monthly Take Home Pay After Deductions:

______________________________ ______________________________ _______________________________

(ATTACH TO THIS AFFIDAVIT COPIES OF THE PAST TWO (2) MONTHS WAGE AND EARNINGS STATEMENTS) Other Incomes: Commissions: Social Security: Child Support: TOTALS MONTHLY HEALTH INSURANCE AND OTHER CHILD PAYMENTS Total Health Insurance Pre-Existing Child Responsibility for Premium Costs: $___________ Support Payments: $_________ Other Children: $________ MONTHLY WORK RELATED CHILD CARE COSTS Child's Name Amount Child's Name Amount Investments: Alimony: Other:

NON-PRORATED MONTHLY EXPENSES Item House Payment/Rent Heat Water Cablevision House Maintenance Life Insurance TOTALS Amount Item Household Food Supplies Electricity Telephone Car Payment Car Insurance Amount

INDIVIDUAL MONTHLY EXPENSES SELF CHILD CHILD CHILD
Name ____________________ Age ___________ Name ___________________ Age ___________

TOTALS

Name _____________________ Age ___________

School & Work Lunch Medical/Dental Drugs Clothing Grooming Laundry/Cleaning Entertainment Recreation Reading Material Church Donations Gifts, Christmas, etc. Club Dues Education Allowances Vacation Gasoline Car Repair & Maintenance Eating Out Other Other Other TOTALS

ASSETS AND DEBTS
Asset Real Estate Vehicles Stocks & Bonds Accounts & Cash Other TOTALS I certify that the aforementioned is true, complete and accurate to the best of my ability. Value Debt Real Estate/Mortgage Vehicle Loans Credit Cards Other Balance Due Monthly Payment

Sworn to and subscribed to before me this ____ day of ____________, 20_______. ___________________________________ Notary Public My Commission Expires:

_________________________________ Affiant