North Carolina > Local County > Wake (District 10)
Certification Of Initial Disclosure (Support) WAKE-DOM-17a - North Carolina
| Certification Of Initial Disclosure (Support) Form. This is a North Carolina form and can be used in Wake (District 10) Local County . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
NORTH CAROLINA COUNTY OF WAKE IN THE GENERAL COURT OF JUSTICE DISTRICT COURT DIVISION FILE NO. ___________________ ___________________________________ , Plaintiff v. ___________________________________ , Defendant CERTIFICATION OF INITIAL DISCLOSURE (SUPPORT) 1. I am the [ ] Plaintiff [ ] Defendant in this action. I have received income during the previous twelve (12) months from the following sources (check all that apply): [ ] Salary or wages [ ] Tips [ ] Commissions [ ] Bonuses [ ] Fees [ ] Severance pay [ ] Income from a business (i.e., distributive share of partnership, shareholder, or LLC income, advances or draws, retained earnings, etc.) [ ] Pensions, retirement pay, distributions and loans from retirement plans [ ] Interest and/or dividends [ ] Income from discharge of indebtedness [ ] Trust income [ ] Annuity income [ ] Income from life insurance and/or endowment contracts [ ] Capital gains (short term and/or long term) [ ] Social Security benefits [ ] Worker's compensation benefits [ ] Unemployment insurance benefits [ ] Disability pay [ ] Gifts or loans [ ] Prizes [ ] Alimony or maintenance from a person not a party to this action [ ] Child support received for children other than the biological or adopted children of the parties [ ] Rental income [ ] Intellectual property income (copyrights, royalties on patents, etc.) [ ] Fringe or employee benefits (health insurance, employer retirement matching, child care benefits, paid vacation, company car, etc.) [ ] Deferred compensation or deferred income [ ] Stock or stock options in lieu of income [ ] Tax refunds received or applied to the next calendar year tax return [ ] Tax credits [] Personal injury, condemnation or other settlement awards American LegalNet, Inc. www.USCourtForms.com WAKE-DOM-17A (2/06) (PAGE 1 OF 4) [] 2. Other: ____________________________________________________________ Time period for which disclosure is required (check one): [ ] This is an initial support claim. (Unless specifically stated otherwise, the documents to be provided shall be for one full calendar year preceding the date of separation through the date of service of the initial disclosures.) [] This is a claim to modify an existing support claim. (Unless specifically stated otherwise, the documents to be provided shall be for the twelve (12) months preceding the filing of the motion to modify through the date of service of the initial disclosures.) INSTRUCTIONS: After the initial disclosures are made, each party has a continuing duty to amend or supplement the original documentation if there has been a change in the form or substance of any of the original information provided. Documents are considered to be in the custody or control of the party if such documents can be obtained by him or her if the party is a joint title or account holder, or if the documents were prepared by a third party (i.e., CPA, accountant, bookkeeper, etc.) at his or her direction or on his or her behalf whether individually or jointly with another. If any of the documents required below have not been provided, in the space following each item you must give a detailed explanation of why the documents are not being provided and indicate what good cause exists for not providing the documents as required. 3. I have provided all of the documents listed below which are in my custody or control to the opposing party/counsel (check all that apply): [ ] Documents showing the income from any source listed in #1 above, including, but not limited to, the following: [ ] Pay stubs, statements, vouchers and/or direct deposit receipts [ ] Employee benefit statements [ ] Stock and stock option statements [ ] Tax forms W-2, 1099, K-1, and other income reporting statements [ ] Other: _______________________________________ [ ] Other: _______________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ [] Company financial statements (whether audited, reviewed or compiled or internal), including, but not limited to balance sheets and profit and loss statements for the past three (3) calendar years through the date of production, if a party is self-employed or is a partner, shareholder, or member holding a 5% or greater interest in a company, business, partnership, joint venture, LLC, corporation or other entity. ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ DOM-17A (2/06) (PAGE 2 OF 4) American LegalNet, Inc. www.USCourtForms.com [] Complete company tax return(s), including all schedules and attachments for the past three (3) calendar years through the date of service of the initial disclosures if a party is self-employed or is a partner, shareholder, or member holding a 5% or greater interest in a company, business, partnership, joint venture, LLC, corporation or other entity. ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Complete federal and state individual tax return(s) filed by the party, or on the party's behalf, including all schedules and attachments (W-2 forms, 1099 forms, etc.) for the past three (3) calendar years prior through the date of service of the initial disclosures, together with all year-end documentation (W-2 forms, 1098 forms, 1099 forms, extension requests, correspondence with the taxing agency, etc.) for the most recent tax year in the event the tax return has yet to be filed (or for the past three (3) calendar years if any of the last three tax year returns have not been filed). ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Documents pertaining to any health, life (term or whole life), casualty, automobile and liability insurance, including, but not limited to, policies, booklets describing benefits of all medical, dental or other health insurance coverage which is or could be available for a child or spouse. ______________________________________________________________________ ___________________________
|
|||||||
