Financial Affidavit

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STATE OF NORTH CAROLINA
IN THE GENERAL COURT OF JUSTICE
COUNTY OF CABARRUS
DISTRICT COURT DIVISION
FILE NO.
Plaintiff,
FINANCIAL AFFIDAVIT
v.
[ ] PLAINTIFF
[ ] DEFENDANT
Defendant.
INCOME INFORMATION
Employer:_________________________________
Employer Telephone: _______________
Employer Address: _______________________________ Social Security No:__________________
Last Taxable Year Adjusted Gross Income:
______________________________
Monthly Gross Before Deductions:
______________________________
Monthly Take Home Pay After Deductions:
_______________________________
(ATTACH TO THIS AFFIDAVIT COPIES OF THE PAST TWO (2) MONTHS
WAGE AND EARNINGS STATEMENTS)
Other Incomes:
Commissions:
Investments:
Social Security:
Alimony:
Child Support:
Other:
TOTALS
MONTHLY HEALTH INSURANCE AND OTHER CHILD PAYMENTS
Total Health Insurance
Pre-Existing Child
Responsibility for
Premium Costs: $___________
Support Payments: $_________
Other Children: $________
MONTHLY WORK RELATED CHILD CARE COSTS
Child’s Name
Amount
Child’s Name
Amount
NON-PRORATED MONTHLY EXPENSES
Item
Amount
Item
Amount
House Payment/Rent
Household Food Supplies
Heat
Electricity
Water
Telephone
Cablevision
Car Payment
House Maintenance
Car Insurance
Life Insurance
TOTALS

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