North Carolina > Local County > Harnett, Lee (District 11A)
Financial Affidavit PC-4 - North Carolina
| Financial Affidavit Form. This is a North Carolina form and can be used in Harnett, Lee (District 11A) Local County . |
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North Carolina County of _____________________________________, Plaintiff, File No. Film No. IN THE GENERAL COURT OF JUSTICE DISTRICT COURT DIVISION v. FINANCIAL AFFIDAVIT OF Plaintiff Defendant (The presiding judge may require this form to be completed.) _____________________________________, Defendant. Date of Separation ____________________________ Employer: Employer Phone No. Employer's Address: I am paid: Weekly Bi-weekly Monthly Other Last Taxable Year Adjusted Gross Income: $ Current Monthly Gross Income before Deductions: $ Current Monthly Take-Home Pay after all Deductions: $ Detail of Monthly Gross Income Monthly gross wages Investment income, interest, dividends Bonus, Commissions Alimony received Child Support received Other (overtime, social security, disability, car allowance, shift pay, vacation/holiday pay) Mandatory Monthly Deductions Federal income tax State income tax Social Security taxes Medicare taxes Retirement Garnishment Other Voluntary Monthly Deductions Heath insurance Dental insurance Vision insurance Life insurance Disability insurance Medical spending account Retirement Other District 11 "Financial Affidavit" (Effective 2-1-07) PC-4 Page 1 of 5 Date of Separation $ $ $ $ $ $ Current $ $ $ $ $ $ Date of Separation $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Current $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ American LegalNet, Inc. www.FormsWorkflow.com County ________________________ File No. ___________________ Part 1 Regular Recurring Monthly Expenses Expense Rent or Mortgage payment Renter's Homeowner's Insurance Taxes not included in mortgage Routine house maintenance Electricity Gas, home heating fuel, oil Water/Sewer Garbage Cable, digital television Home phone Cell phone Internet service Yard maintenance Home security system House cleaning service Pest control services Automobile payment Automobile insurance Automobile gasoline Auto maintenance (tags, taxes, registration) Food Household supplies Pet upkeep Other Other Other Other Other Other Other Other Other Other PART 1 TOTAL District 11 "Financial Affidavit" (Effective 2/1/07) PC-4 Page 2 of 5 Date of Separation _________________ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Current date ______________ American LegalNet, Inc. www.FormsWorkflow.com County _______________________ File No. _______________________ PART 2 INDIVIDUAL MONTHLY EXPENSES Date of Separation ____________________ Expense Self Medical insurance premium Dental/Vision insurance Uninsured Medical expenses Uninsured dental/orthodontics Uninsured prescription/OTC meds. Other uninsured medicals Other insurance premiums Work related child care Summer camp Cellular phone Eating out School lunches Newspapers/magazines Clothing and accessories Personal upkeep Laundry/Dry Cleaning Education fees/supplies Babysitting, misc. child care Extracurricular activities Church/charity donations Other Other Other Other Other Other PART II - INDIVIDUAL MONTHLY EXPENSES TOTAL $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Children $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Total $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Self Children $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Total Current date _________________________ District 11 "Financial Affidavit" (Effective 2-1-07) PC-4 Page 3 of 5 American LegalNet, Inc. www.FormsWorkflow.com County _________________ File No. _____________________ PART II (Continued) INDIVIDUAL MONTHLY EXPENSES Expense Other Charitable contributions Entertainment/Recreation Club dues/assessments Allowances for child(ren) Annual vacation Gifts (birthdays, holidays) Child support for another child Spousal support Professional fees School loans Retirement Investments Savings College fund Other Other Other Other Other PART II, PAGE 2 TOTAL $ PART II, PAGE 1 TOTAL $ PART II TOTAL $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Date of Separation ____________________ Self Children Total $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Current date _________________________ Self Children Total $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ District 11- "Financial Affidavit" (Effective 2-1-07) PC-4 Page 4 of 5 American LegalNet, Inc. www.FormsWorkflow.com County ___________________ File No. ______________________ PART III DEBTS Creditor Balance DOS $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Monthly Payments $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Current Balance Due $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Monthly Payment $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ PART III $ TOTAL Date: ______________________ District 11 "Financial Affidavit" (Effective 2-1-07) PC- 4 Page 5 of 5 ____________________________________________ Plaintiff Defendant American LegalNet, Inc. www.FormsWorkflow.com
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