Form #4 - Financial Affidavit - Pitt County General Court Of Justice
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6Form #4
STATE OF NORTH AROLINA
In the General Court of Justice
PITT COUNTY
District Court Division
File No.
Plaintiff:
VERSUS
FINANCIAL AFFIDAVIT OF
Defendant:
Plaintiff___________
Defendant _________
Employer: ______________________________________________________________________
Employer Address: _______________________________________________________________
I am paid: ( ) weekly ( ) every other week, ( ) twice monthly,
( ) monthly
( ) other (explain): _______________________________________________________________
Last Taxable Year Adjustable Gross Income:
Current Monthly Gross Income before Deductions:
Current Monthly Net Income after Mandatory Deductions:
Detail of Monthly Gross Income
Date of Separation
Current
Monthly Gross Wages:
Investment income, interest, dividends:
Bonus, commissions:
Alimony received:
Spousal Support received:
Other (overtime, social security, disability,
car allowance, shift pay, vacation/holiday
pay):
TOTAL MONTHLY GROSS INCOME
Mandatory Monthly Deductions
Date of Separation
Current
Federal income tax:
State income tax:
Social Security taxes:
Medicare taxes:
Retirement:
Garnishment:
Other: __________________
TOTAL MANDATORY DEDUCTIONS
Voluntary Monthly Deductions
Date of Separation
Current
Health Insurance:
Dental Insurance:
Vision Insurance:
Life Insurance:
Disability Insurance:
Medical Spending Account:
Retirement:
Other:
TOTAL VOLUNTARY DEDUCTIONS
Pitt County Family Court Domestic Forms, 2017
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