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: City/State/Zip:
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:
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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: Child's name
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: Child's name
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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 69 of 90 consecutive nights? More than an annual total of 164 nights? ________ Yes ________ Yes ________ No ________ No
If you answered yes to either of the last two questions, please provide the total number of courtordered visitation night 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
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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: Employer City, State, Zip: Date you started working for this employer: Occupation:
Hourly Monthly Annually
$ $ $
Per hour Per month per year
Hours per week
Number of pay periods (check one) Weekly 24 per year (paid twice per month) 26 per year (paid every two weeks) Monthly Other
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Overtime: Average number of overtime hours worked per week during the past 12 months: Rate of pay for overtime hours: $ Commission and tips: Commissions: $ Tips: Bonuses: Please provide information about the type and amount of any bonuses you have received in the past 12 months: $ per per
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 provide Annual value
Total Value
0
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
Total Value 5
0
Union dues: $ Name of Union: Are union dues required as a condition of employment? List any professional/occupational licenses you hold: ______ Yes _______ No per month
Annual professional/occupational license fee: $ Is this fee paid or reimbursed by your employer? Is this license required as a condition of employment? Yes Yes No No
Are you required, as a condition of employment to contribute to a retirement plan? Yes If yes, monthly amount of required contribution: $ No
Employee Expenses: Do you have out-of-pocket expenses for special equipment or clothing required as a condition of your employment? Yes No Yes $ No
If yes, are you reimbursed for these expenses?
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 Yes No
If yes, are you reimbursed for these lodging expenses
If no, please provide the number of overnights in the last calendar year: and this year to date:
3.
HEALTH INSURANCE AND MEDICAL EXPENSES Yes No
Do you have access to dependant health insurance coverage? 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: ______________________ ____________________
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Cost for health insurance is (complete all options that are available):
Single plan
$
per per per
Single + dependant plan $ Family plan $
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 $ $ $ $ Total amount
0
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 our 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 of last employer: Employer Address: Employer City, State, Zip: Occupation:
Wages for last employment (complete the option that best described your situation) Hourly Monthly Annually $ $ $ Per hour Per month per year Hours per week
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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 past 12 months of your last employment $ Rate of pay for overtime hours: $ Commission and tips for last employment: Commissions: $ Tips: Bonuses: Please provide information about the type and amount of any bonuses you received during the final 12 months of your last employment: $ per per
Did you receive severance pay when you became unemployed? If yes, amount received: $
Yes
No
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.
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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
PERCENTAGE
Name of business entity: Address: City/State/Zip:
TYPE OF BUSINESS Farming/Ranching Service Retail Sales Wholesale Sales Other (please described)
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
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Names of household members who work in this business, the wage/salary paid to the household member, and household member's job duties: Household member's name Wage/Salary Job Duties
6.
OTHER INCOME
Workers' compensation Benefits Social security disability 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 per per
7. COMMENTS Please use this section to provide any other information that you feel would help the court understand the situation:
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8.
SIGNATURE
I state, under penalty of perjury, that the information contain in, and attached to, this Financial Affidavit, is true and correct to the best of my knowledge.
Date:
Signature:
State of
County of
Subscribed and sworn to before on
, 20
.
(Seal) Notary Public My commission expires:
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