Free Alternate Financial Affidavit - North Dakota

FINANCIAL AFFIDAVIT This affidavit will help you present information to the court for use in determining the correct amount of child support based on the North Dakota Child Support Guidelines. Please complete this form and sign it in front of a Notary Public. If you need more space, please attach additional pages. Additional information can also be added in the Comment section at the end. Attach all requested documents and additional pages and return to ____________________________________________________________________. 1. PERSONAL BACKGROUND Name: _____________________________ Address: _____________________________ _____________________________ ______________________________ List the names and dates of birth of your biological or adopted children who live with you: Child's name Date of birth ______________________________ __________________ ______________________________ __________________ ______________________________ __________________ ______________________________ __________________ List the names and dates of birth of your biological or adopted children who do not live with you and the name of the person with whom each child lives: Child's Name Date of birth Lives with ______________________________ __________________ ________________ ______________________________ __________________ ________________ ______________________________ __________________ ________________ ______________________________ __________________ ________________ List the children you claim as exemptions on your federal income tax return. If any of these children are not your biological or adopted children, please indicate the relationship (for example, stepchild). Child's name Relationship _________________________________ ________________ _________________________________ ________________ _________________________________ ________________ _________________________________ ________________ Do you alternate claiming the exemption for any of your biological or adopted children with the other parent of those children? _____ Yes _____ No

If yes, list the names of the children for whom the exemption is alternated: __________________________________________ __________________________________________ __________________________________________ __________________________________________ Are any of your biological or adopted children for whom you claim an exemption qualifying children for purposes of the child tax credit? _____ Yes _____ No If yes, list the names of the children who are qualifying children for purposes of the child tax credit: __________________________________________ __________________________________________ __________________________________________ __________________________________________ Do you and the other parent in this child support matter have split custody of your children? (Split custody means that you and the other parent have more than one child in common and you and the other parent each have custody of at least one child.) _____ Yes _____ No Do you and the other parent in this child support matter have equal physical custody of your children? (Equal physical custody means each parent, by court order, has physical custody of the children exactly fifty percent of the time.) _____ Yes _____ No Does a court order specify when you have visitation with your children? _____ Yes _____ No If yes, according to the court order, is the number of nights any of your children spend with you: more than 60 of 90 consecutive nights? _____ Yes _____ No more than an annual total of 164 nights? _____ Yes _____ No If you answered yes to either of the last two questions, please provide the total number of court-ordered visitation nights per child, per year: Child's Name Total number of visitation nights per year _____________________ __________ _____________________ __________ _____________________ __________ _____________________ __________ Do the children in this child support matter receive any governmental or other benefits on your account? (Examples include dependent's benefits from the Social Security Administration based on your disability or retirement.)

_____ Yes

_____ No

If yes, list the names of the children, the type of benefit they are receiving, and the monthly amount of such benefit: Child's name Type of benefit Monthly amount ________________________ ______________________ _____________ ________________________ ______________________ _____________ ________________________ ______________________ _____________ ________________________ ______________________ _____________ 2. EMPLOYMENT If you are working full-time (at least 40 hours per week) for at least one employer, earning at least minimum wage ($5.15 per hour), and have not changed jobs resulting in a reduction of income within the past three years, please attach a copy of your most recent federal income tax return. Include copies of all W-2 forms, 1099 forms, and schedules. Also, include copies of pay stubs showing your year-to-date income. If you are only working part-time for one or more employers, earning less than minimum wage, or have changed jobs resulting in a reduction of income within the past three years, please attach copies of your last three federal income tax returns. Include copies of all W-2 forms, 1099 forms, and schedules. Also, include copies of your pay stubs showing year-to-date income from each employer. For confidentiality reasons, black out all social security numbers and financial account numbers that appear on the tax forms and pay stubs you are attaching. If you do have more than one employer, answer the questions in this section based on your primary job. Then attach additional pages to provide the same kind of information for each of your other jobs. Employer name: ________________________________ Employer address: ______________________________ ______________________________________________ Date you started working for this employer: _______________ Occupation: ________________________________________ Rate of pay (complete the option that best describes your situation) Hourly: $________ per hour; ________ hours per week Monthly: $________ per month Annually: $________ per year Number of pay periods (check one) _____ weekly

_____ _____ _____ _____

24 per year (paid twice per month) 26 per year (paid every two weeks) monthly other ___________________________

Overtime Average number of overtime hours worked per week during the past 12months: ________ Rate of pay for overtime hours: $________ Commissions and tips Commissions: $________ per __________ Tips: $________ per __________ Bonuses Please provide information about the type and amount of any bonuses you have received in the past 12 months: ______________________________________ ________________________________________________________________ ________________________________________________________________ Employee benefits Describe the benefits provided to you by your employer and the annual value of such benefit (examples may include paid vacation and sick leave, health insurance, employer retirement contributions, etc.): Benefit provided Annual value _________________________________________ __________ __________________________________________ __________ __________________________________________ __________ __________________________________________ __________ In-kind Income Describe any in-kind income provided to you by your employer and the annual value of such income. (In-kind income means you are allowed to use your employer's property or you are being provided with services at no charge or less than the customary charge. Examples include the use of living quarters, and being provided with transportation, groceries, or utilities.) In-kind income received Annual value _________________________________________ __________ _________________________________________ __________ _________________________________________ __________ _________________________________________ __________ Union dues: $________ per month Name of union: ________________________ Are union dues required as a condition of employment? _____ Yes _____ No List any professional/occupational licenses you hold: ________________________

Annual professional/occupational license fee: $_______ Is this fee paid or reimbursed by your employer? _____ Yes Is this license required as a condition of employment?____ Yes

_____ No _____ No

Are you required, as a condition of employment, to contribute to a retirement plan? _____ Yes _____ No If yes, monthly amount of required contribution: $__________ Employee expenses Do you have out-of-pocket expenses for special equipment or clothing required as a condition of your employment? _____ Yes _____ No If yes, are you reimbursed for these expenses? _____ Yes _____ No If no, what are your annual out-of-pocket expenses for these items? $_______ Do you have out-of-pocket expenses for lodging when you must travel as a condition of your employment? _____ Yes _____ No If yes, are you reimbursed for these lodging expenses? _____ Yes _____ No If no, please provide the number of overnights in the last calendar year: ________ and this year to date: ________ 3. HEALTH INSURANCE AND MEDICAL EXPENSES Do you have access to dependent health insurance coverage? _____ Yes _____ No If yes, please provide the following information: Are you enrolled in the health insurance plan? _____ Yes _____ No If you are enrolled in the plan, please provide the names of persons, including yourself, covered under the plan: ______________________________ ______________________________ ______________________________ ______________________________ _______________________________ Name of policyholder: _________________________ Cost for health insurance is (complete all options that are available): Single plan: $_______ per ________ Single + dependent plan: $________ per ________ Family plan: $_______ per ________ Annual amount of out-of-pocket medical expenses you pay for the children in this child support matter to the extent those expenses are likely to continue: Child's name Annual amount ____________________ $___________ ____________________ $___________ ____________________ $___________

4. UNEMPLOYMENT If you are currently unemployed, please provide the following information about your last employment. Also, please attach copies of your last three federal income tax returns. Include copies of all W-2 forms, 1099 forms, and schedules. For confidentiality reasons, black out all social security numbers and financial account numbers that appear on the tax forms you are attaching. Reason for unemployment: __________________________________________ Date you became unemployed: ______________________________________ Name and address of last employer:___________________________________ ___________________________________ Occupation: ______________________________________________________ Wages for last employment (complete the option that best described your situation) Hourly: $________ per hour; ________ hours per week Monthly: $________ per month Annually: $________ per year Number of pay periods for last employment (check one) _____ weekly _____ 24 per year (paid twice per month) _____ 26 per year (paid every two weeks) _____ monthly _____ other ________________________________________________ Overtime Average number of overtime hours worked per week during the final 12 months of your last employment: ________ Rate of pay for overtime hours: $________ Commissions and tips for last employment Commissions: $________ per __________ Tips: $________ per __________ Bonuses Please provide information about the type and amount of any bonuses you received during the final 12 months of your last employment: ______________________ _______________________________________________________________ _______________________________________________________________ Did you receive severance pay when you became unemployed? _____ Yes _____ No If yes, amount received: $_________ 5. SELF-EMPLOYMENT If you are self-employed, please attach copies of your personal and business federal

income tax returns for the past five years. These include IRS forms 1040, 1065, 1120, and 1120S, as well as all related schedules. For confidentiality reasons, black out all social security numbers and financial account numbers that appear on the tax forms you are attaching. If you have more than one self-employment activity, answer the questions in this section based on your primary activity. Then attach additional pages to provide the same kind of information for each of your other activities. Structure of business entity: _____ Sole proprietorship _____ Partnership; percent ownership interest: _____ _____ Limited liability company; percent ownership interest: _____ _____ S Corporation; percent ownership interest: _____ _____ C Corporation; percent ownership interest: _____ Name of business entity: _______________________ Business address: ____________________________ ____________________________ Type of business: _____ Farming/ranching _____ Service _____ Retail sales _____ Wholesale sales _____ Other; please describe: ____________________________ Description of business activity (e.g., type of service provided, type of item(s) sold, etc.): _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ How long has this business been in existence? _____ years _____ months Names of household members who work in this business, household member, and household member's job duties: Household member's name Wage/salary ______________________ __________ ______________________ __________ ______________________ __________ 6. OTHER INCOME Workers' compensation benefits Social security disability the wage/salary paid to the Job duties ____________________ ____________________ ____________________

$_______ per __________ $_______ per __________

Social security retirement Dividends and interest Railroad retirement Veterans' benefits Other pension or retirement benefits Trust income Unemployment compensation Gifts and prizes of more than $1,000/year Refundable tax credits Gains Spousal support (alimony) payments received Military subsistence payments received Rental income Other (specify)_________________________

$_______ per __________ $_______ per __________ $_______ per __________ $_______ per __________ $_______ per __________ $_______ per __________ $_______ per __________ $_______ per __________ $_______ $_______ $_______ per __________ $_______ per __________ $_______ per __________ $_______ per _________

7. COMMENTS Please use this section to provide any other information that you feel would help the court understand your situation: _______________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 8. Signature I state, under penalty of perjury, that the information contained in, and attached to, this Financial Affidavit, is true and correct to the best of my knowledge. Date: _______________ STATE OF ________________ County of _________________ Subscribed and sworn to before me on ______________, ______. (SEAL) ________________________________ __________________, Notary Public My commission expires:_____________ Signature: ____________________________