North Carolina > Local County > Durham (District 14)
Affidavit (Employer Wage Affidavit) 7 - North Carolina
| Affidavit (Employer Wage Affidavit) Form. This is a North Carolina form and can be used in Durham (District 14) Local County . |
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FORM 7 (Rev. 1/06) NORTH CAROLINA 14TH JUDICIAL DISTRICT DURHAM COUNTY IN THE GENERAL COURT OF JUSTICE DISTRICT COURT DIVISION _______-CVD- __________ ________________________________, Plaintiff -v- AFFIDAVIT (Employer Wage Affidavit) ________________________________, Defendant I, _____________________________________, (please print name) a Personnel Officer, being duly sworn, deposes and says: 1. That I am an employee of __________________________________ [name of company] located at _____________________________________________ [provide full address]; and 2. That ________________________, the an employee of said company; and Plaintiff, or Defendant in the above entitled action, is 3. That the records attached hereto of Plaintiff's, or Defendant's earnings, deductions, company benefits, and length of employment are true and correct to the best of affiant's information and belief. 4. That my work telephone number is ________________________. This the ____day of ______________, 20___. __________________________________ Affiant (Personnel Officer) __________________________________ Title Subscribed and sworn before me this the ___ day of ______________, _____. ________________________________ Notary Public My commission expires: ____________ Page 1 of 3 American LegalNet, Inc. www.USCourtForms.com FORM 7 (Rev. 1/06) EARNINGS INFORMATION 1. Earnings last calendar year, including bonus, if any: a. Gross: $ _____________ b. Net: $ _____________ 2. Present rate of pay: $________ per ________ [insert time period, i.e., week, month, etc.] * If Employee is paid on production or commission, what is present average gross pay? $_________ per _________ [insert time period, i.e., week, month, etc.] 3. How often is employee paid? _________________ 4. Number of hours working per day? ____________ 5. Number of days working per week? ____________ 6. Deductions from gross pay per pay period: a. State taxes: $__________ b. Federal taxes: $__________ c. FICA: $__________ d. Medical Insurance $__________ i. How much of medical insurance premium is allocated for coverage of children? $_________ per ________. ii. Does medical insurance include medical, dental and/or other coverage? If so, what health care services are covered? _______________________________ iii. What are the terms of the deductible payments required under the medical coverage provided? ______________________________________________ 7. Number of exemptions claimed: _________ 8. Date employee last paid: _______________ 9. How many pay periods, if any, are employee's earnings retained by employer? ___________ 10. Earnings this calendar year through date employee was last paid, including bonus, if any: a. Gross: $__________ b. Net: $__________ 11. Is employee paid a bonus? _______ (yes or no) If yes, explain: a. How bonus is computed: ________________________________________________ b. When bonus is paid: ____________________________________________________ c. Amount paid last calendar year: ______________ d. Amount paid this calendar year: ______________ 12. What pay increase, if any, has employee received in the past twelve months? _____________ 13. Nature of employment: _______________________________________________________ 14. Date(s) of Hire/service: ______________________________________________________ 15. Amount paid by employer on employee's behalf for: Medical Insurance: $________ per ________ Retirement: $________ per ________ Disability Insurance: $________ per ________ Dues: $________ per ________ Reimbursed expenses: $________ per ________ Page 2 of 3 American LegalNet, Inc. www.USCourtForms.com FORM 7 (Rev. 1/06) INSTRUCTIONS TO COMPLETE EMPLOYER AFFIDAVIT OF INCOME AND BENEFITS 1. The Employer Affidavit of Income and Benefits is for the purpose of providing information and records to the Court concerning a party's income and employee benefits that will assist the court in making decisions relative to financial aspects of the party's case now pending. 2. If you are the custodian of records for your employer and you or your employer have been served with a subpoena commanding you or the employer to appear in court for the sole purpose of producing records in the possession and control of the employer, you may, in lieu of a personal appearance, tender to the court by registered mail, certified copies of the records requested together with an affidavit by the custodian as to the authentication of the records tendered, or, if no such records are in the employer's custody, an affidavit to that effect. 3. Please complete the attached employer affidavit if you are the person who is the designated custodian of records for the employer from whom the records have been subpoenaed. 4. Copies of the records are deemed "certified" if they are appended to the affidavit attached to these instructions and referred to in the affidavit. 5. If you have any of the following records in your possession and control, they should be identified in and appended to the Employer Affidavit: a. Three (3) years worth of income information through the date of production should be produced. The meaning of the word "income" is as defined by the Internal Revenue Service and includes bonuses and commissions; b. For the last full year prior to production of records, all records pertaining to any voluntary or involuntary deductions by the employer or employee as well as monthly records for the year in which the request for production is made if not a full calendar year; c. For the last full year prior to production of records, all records pertaining to any employee benefits, including but not limited to health insurance (including medical, dental and other healthcare related), retirement benefits including employer matching, deferred compensation, stock options, life or disability insurance, car lease and expense reimbursement, cell phone or computer use or lease paid, frequent flyer miles, vacation, sick leave, paid leave, country club, health club, or other memberships or dues. d. Copies of any retirement plan and health care plan including family and dependent coverage in effect for the employee. Copies of any employment agreement or stock option agreement or non-compete agreement. e. Inclusive dates of employment for any consecutive and non-consecutive periods for the last five years Page 3 of 3 American LegalNet, Inc. www.USCourtForms.com
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