State Of Alabama Form Cs-41 Child-Support-Obligation Income Statement/affidavit
Download a blank fillable State Of Alabama Form Cs-41 Child-Support-Obligation Income Statement/affidavit in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete State Of Alabama Form Cs-41 Child-Support-Obligation Income Statement/affidavit with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2State of Alabama
Case Number
CHILD-SUPPORT-OBLIGATION
Unified Judicial System
INCOME STATEMENT/AFFIDAVIT
Form CS-41
Rev. 4/15
IN THE ____________________________ COURT OF __________________COUNTY, ALABAMA
(Circuit or District)
(Name of County)
Plaintiff _____________________________ v.
Defendant _________________________________
AFFIDAVIT
I, ____________________________________________, being duly sworn upon my oath, state as follows :
(Name of Affiant)
1. I am the
Plaintiff
Defendant
Other (please specify):_________________ in the above matter.
My Social Security number is:_____________________________________
2. I am
currently employed. My employer’s name and address are:
_____________________________________________________________________
_____________________________________________________________________
not currently employed.
My last employer’s name and address are: _______________________________________
_________________________________________________________________________
Last position title: __________________________________________________________
Average monthly salary in the last year of employment: $ ___________________________
3. My monthly gross income includes:
(For example of income that must be included, see back of this form. If income varies by month, enter the estimated average monthly gross income.)
Employment income
$______________________________
Self-employment income
$______________________________
Other employment-related income
$______________________________
Other non-employment-related income
$______________________________
Total
$_______________________________
4. I incur the following amount monthly for work-related
child-care:
$______________________________
(if none, write “None”)
5. The child(ren) of the parties is/are
not covered by health insurance from me and/or my employer.
covered by health insurance, and (1) I pay $_______ each month, or that amount is paid on my behalf each
month by my________, for the family policy coverage under which the child(ren) is/are covered; and (2) the total
number of persons covered under that policy is ________________.
The pro rata portion of the medical insurance premium attributable to the child or children who are the
subject of the support order (which shall be calculated by dividing the total medical insurance premium actually paid
by, or on behalf of, the parent ordered to provide the coverage by the total number of persons (adult and/or
children) covered and then multiplying the result by the number of children who are the subject of the support
order) is the sum of $_______________ .
6. I pay the following total amount for
child support
alimony in [a] prior
case(s) as follows:
[List case number(s) and county(ies) and state(s) here]:
__________________________________________
$______________________________
(if none, write “None”)
__________________________________________
I understand that I will be required to maintain all income documentation used in preparing this Income Statement/Affidavit (including
my most recent income-tax return) and that such documentation shall be made available as directed by the court. I also understand
that any intentional falsification of the information presented in this Income Statement/Affidavit may subject me to the penalties of
perjury.
______________________________________________
Affiant
Sworn to and subscribed before me this ______
day of _______________________, ________
______________________________________
Notary/Clerk
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Csed 04-1017 - Application For Child Support Enforcement Services And Affidavit Of Support Received And Affidavit And Request For Address Confidentiality - Alaska Division Of Child Support Enforcement
Legal
Related Categories
Parent category: Legal