Kansas > Local District Court > 29th Judicial District (Wyandotte County)
Domestic Relations Affidavit - Kansas
| Domestic Relations Affidavit Form. This is a Kansas form and can be used in 29th Judicial District (Wyandotte County) Local District Court . |
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IN THE DISTRICT COURT OF WYANDOTTE COUNTY, KANSAS IN THE MATTER OF: ___________________________ Petitioner ___________________________ Respondent DOMESTIC RELATIONS AFFIDAVIT 1. Mother/Wife _________________ __________________ ___________________ Date of Birth Social Security # # of Marriages _________________________________________________ _________________________ Mailing Address Daytime Phone Number 2. Father/Husband _________________ __________________ ___________________ Date of Birth Social Security # # of Marriages ______________________________________________ __________________________ Mailing Address Daytime Phone Number 3. Date of Marriage: _____________ Number of Children of this Marriage or Relationship: _______ 4. The minor children of this marriage or relationship are: Social Security Number Child's Income & Birth Date Assets, If Any $ $ $ / / / / / / Case No. ___________ Court No. ___________ Chapter 60 Name 1. 2. 3. Age ____ ____ ____ 4. -$ / / ____ 5. Health and dental insurance coverage for the children in this case (not including cost of coverage for parents) is: Insurance Company Name ________________________________________________________ Policy No. ____________________ Group No. __________________ Monthly Premium $ ______________ Paid by ____________________ 6. Child care expenses for the children in this case which I must pay so that I can work outside the home or look for work (Child Care Verification Form must be attached): Name of Provider _______________________________________________________________ Address _________________________________________________________________ Monthly Cost $ _____________ Minus Tax Credit* $ ______________________ *See Attachment for directions on computing tax credit. American LegalNet, Inc. www.USCourtForms.com 7. Not including the children in this case, I have been ordered to pay, and am paying, child support or maintenance for: Name 1. 2. 3. 4. Age ` ` ` ` Monthly Amount $ $ $ $ Court ` ` ` ` 8. Not including the children in this case, and not including step-children, I am supporting the following children who are living with me as my children by birth or adoption: Name 1. 2. 3. 4. Age ` ` ` ` Relationship ` ` ` ` 9. Child Support Adjustments Requested: (The requesting party must prove the basis for adjustments). ITEM Substantial & reasonable costs of long distance visitation with Children Time spent with Non-Custodial parent (over 30% of time and/or more than 30 consecutive days) Unreasonable refusal to share, (divide or alternate) Income Tax Exemptions. (IRS Form 8332) Special Needs of the children (greater than usual expenses & uninsured medical costs) Agreement to support a child past minority (when custodian seeks increase for children under 18) Cost of living differential (between different geographic regions of the United States) Residence with Third Party (apportion between parents the support to be paid to third party) Overall Financial Condition (justifying adjustment in the best interest of the children) (+/-) (+/-) (+/-) (+/-) (+/-) (+/-) (+/-) (+/-) (+/-) Requested Adjustment $ $ $ $ $ $ $ $ 10. Has public assistance (welfare) been expended for any of the children in this case? If yes, _______________, _______________, and dates ___________to __________ State County Start End 11. Attached to this Domestic Relations Affidavit are my most recent paycheck stubs with year-to-date totals, last year's Income Tax Return, Employer Verification Form and Child Care Verification Form (if applicable). 12. Mother/Wife is employed by ______________________________________________ Name and Address of Employer The pay period of Mother/Wife is: weekly __ every 2 wks __ twice a month __ monthly __ other __ Father/Husband is employed by____________________________________________ Name and Address of Employer The pay period of Father/Husband is: weekly __ every 2 wks __ twice a month __ monthly __ other __ American LegalNet, Inc. www.USCourtForms.com A. Monthly Wage or Salary 1. Gross Income 2. Other Income 3. Subtotal Gross Income 4. Withholding Tax Exemptions Claimed 5. Federal Income Tax 6. OASDHI (Social Security) 7. State Withholding 8. Subtotal Deductions from Pay 9. Net Monthly Income B. Monthly Income from Self-Employment 1. Gross Income from Self-Employment 2. Other Income 3. Subtotal Gross Income 4. Reasonable Business Exp. (attach itemized list) 5. Withholding Tax Exemptions Claimed 6. Federal Income Tax 7. State Income Tax 8. Self-Employment Tax 9. Subtotal Deductions 10. Net Monthly Income Mother/Wife $ $ $ $ $ $ $ $ $ Mother/Wife $ $ $ $ $ $ $ $ $ $ Father/Husband $ $ $ $ $ $ $ $ $ Father/Husband $ $ $ $ $ $ $ $ $ $ 12. UNEMPLOYED: Are you receiving Unemployment Compensation? How much per week? _____________ How many weeks are you eligible for? ______________ VERIFICATION UNDER OATH STATE OF _____________________) COUNTY OF ___________________) I swear or affirm under penalty of perjury that the information presented in this affidavit is true and complete. Signature_________________________________ ________________________________________ Date Signed Subscribed and sworn to before me on this _____ day of _____________________, ______. _____________________________________ Notary Public My Commission Expires: ___________________ American LegalNet, Inc. www.USCourtForms.com DOMESTIC REALATIONS AFFIDAVIT Monthly Expense Attachment: The monthly expenses of each party are: (Please indicate with an asterisk all figures which are estimates rather than actual figures taken from records.) A. Item 1. House payment, rent or mortgage 2. Food 3. Utilities Trash Newspaper Telephone Gas Water Lights Other 4. Insurance: Life Health Car House Other 5. Uninsured health 6. Child Care 7. Clothing 8. School expenses 9. Hair cuts and beauty 10. Car Repair 11. Gas & Oil 12. Personal property tax 13. Miscellaneous (specify) $ $ TOTAL OF MONTHLY EXPENSES $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Mother/Wife $ $ Father/Husband $ $ American LegalNet, Inc. www.USCourtForms.com CHILD CARE TAX CREDIT COMPUTATION The tax credit is a percentage of the custodial parent's actual or maximum child care cost per month, (not to exceed $200.00 for one child, or $400 for two or more children), determined by adjusted gross income of the custodial parent. Adjusted Gross Income Greater than $0 $10,000 $12,000 $14,000 $16,000 $18,000 $20,000 $22,000 $24,000 $26,000 $28,000 But less than $10,000 $12,00
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