North Carolina > Local County > Durham (District 14)
Financial Affidavit 6 - North Carolina
| Financial Affidavit Form. This is a North Carolina form and can be used in Durham (District 14) Local County . |
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FORM 6 (Rev 4/01) NORTH CAROLINA IN THE GENERAL COURT OF JUSTICE TH 14 JUDICIAL DISTRICT DISTRICT COURT DIVISION DURHAM COUNTY _______ -CVD- __________ FINANCIAL AFFIDAVIT ________________________________, FOR: Plaintiff Plaintiff -v- Defendant TYPE OF SUPPORT SOUGHT: PSS/Alimony Child Support ________________________________, PARTY FROM WHOM SUPPORT I S SOUGHT: Defendant Plaintiff Defendant NUMBER OF MINOR CHILDREN __________ OTHER DEPENDENTS IN HOME __________ The affiant, having been first duly sworn as to the truthfulness and completeness of this affidavit, deposes and says that the average monthly financial needs for the support of the children in this case and/or my monthly income and expenses are as follows: PART I - INCOME INFORMATION For all types of cases, please complete Part I, attach necessary documents, and have your signature notarized on page 2. 1. My name is: (please print)_________________________________________. 2. My social security number is: _____________________________. 3. I am: a. __ Self-employed doing:_____________________________________________ or, b. __ Employed by: (First Job)____________________ (Second job)_______________________ c. Employers Address(es)______________________ ______________________________ ______________________ ______________________________ d. Employers Telephone(s)_____________________ ______________________________ 4. I receive the following AVERAGE MONTHLY GROSS INCOME (based on 4.33 weeks per month, or 2.165 bi-weekly periods per month) from the following sources: a. Wage / Salary $ __________ e. Rent $ __________ b. Bonuses $ __________ f. Business Profit $ __________ c. Commissions $ __________ g. Social Security $ __________ d. Interest /Dividends / h. Pension / Retirement $ __________ Investments $ __________ i. Other $ __________ TOTAL $ __________ 5. I have the following average MONTHLY expenses in connection with my business profit and/or rental income (including only expenses [and not depreciation] that are deductible on Schedule "C" and/or "E" of my IRS Form 1040 income tax return): __________________________________________ $__________________ __________________________________________ $__________________ __________________________________________ $__________________ TOTAL EXPENSES $__________________ 1 <<<<<<<<<********>>>>>>>>>>>>> 2 FORM 6 (Rev 4/01) PART II - CHILD SUPPORT INFORMATION - GUIDELINE CASES For all Child Support Guideline Cases, please complete Part II, attach all documents, and have your signature notarized on this page. 1. I have the following average MONTHLY expenses: A. Court-ordered or Separation Agreement required child support for my children who are not living with me. $ ____________ Names and dates of birth for children NOT living with me: ___________________________ ____________________________ ___________________________ ____________________________ ___________________________ ____________________________ ___________________________ ____________________________ ___________________________ ____________________________ B. Responsibility for my biological or adopted children who live with me (calculated per N.C. Guidelines). $ ____________ Names and dates of birth for children living with me: ___________________________ ____________________________ ___________________________ ____________________________ ___________________________ ____________________________ ___________________________ ____________________________ ___________________________ ____________________________ C. Gross monthly income of other parent responsible for children listed in A $ ___________A and B above. $ ___________B D. Monthly work-related child care costs (100%) $ ____________ E. Child(ren)s portion of health insurance cost $ ____________ F. Extraordinary expenses for child(ren) (Please itemize as defined on page 4 of the N.C. Guidelines) ____________________________________________________ $ ____________ ____________________________________________________ $ ____________ 2. Number of overnights the child(ren) spend(s) with me each year ___________ I have attached to this document and therefore made a part of this document, copies of my PAY STUBS for the past two (2) months (or other official documentation of my income), and my latest FEDERAL TAX RETURN including all schedules with attached W-2s & 1099s. STATE OF _____________________ VERIFICATION COUNTY OF ___________________ Being first duly sworn, I depose and say that I have read the foregoing pages and I know the contents thereof and that the contents are true to my knowledge, except as to those matters and things stated upon information and belief, and as to those matters and things, I believe them to be true. ______________________________ Sworn to and subscribed before me Affiant this ____ day of ____________, _____. _______________________________ Notary Public My Commission Expires:____________ 2 <<<<<<<<<********>>>>>>>>>>>>> 3 FORM 6 (Rev 4/01) PART III SPOUSAL SUPPORT, NON-GUIDELINES, OR DEVIATION FROM GUIDELINES For all Spousal Support Cases, and all Non-Child Support Guideline Cases, or Deviation of Child Support Cases, please complete Part III, attach documents, and have your signature notarized on pages 2 and 5. A. INCOME: My total GROSS MONTHLY INCOME IS: (From Part I) $ _________ (Line 1) I have the following average monthly deductions from my gross income Federal income taxes $ __________ State income taxes $ __________ Social Security $ __________ Medicare $ __________ Medical insurance $ __________ Life Insurance $ __________ Retirement / 401(K) $ __________ Other $ __________ TOTAL amount of average deductions $ __________ (Line 10) My average MONTHLY NET INCOME IS: $ __________________ (Line 1 minus Line 10) ** NOTE: One month equals 4.33 weeks (or 2.165 bi-weekly periods) B. NEEDS AND EXPENSES FIXED HOUSEHOLD EXPENSES (Average monthly needs and expenses) Expense and/or Actual Anticipated Expense and/or Actual Anticipated Need Expense Expense Need Expense Expense House payment / Rent Telephone Property tax (if not House maintenance included above) Homeowners or Yard maintenance Renters insurance Electricity Car payment Water Gasoline Cable Car repairs Garbage Car insurance Other (specify) Other (specify) TOTALS COMBINED TOTALS For All Actual and Anticipated Expenses $ $ I have PRORATED the foregoing actual and anticipated fixed family expenses between the child(ren) and me as follows: Total amount for self: $____________ (monthly) $______
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