Financial Affidavit For Child Support Page 4
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86. I believe my spouse is capable of earning more income than is currently
being earned. I base this on past employment at ____________________,
(name of employer)
where my spouse’s gross income per month was $____________________,
(amount of income from all sources)
based on (choose one):
[ ] $_________ per hour for ___________hours per week.
(amount per hour)
(number of hours)
OR
[ ] $___________ salary per month plus monthly bonuses of
(amount per month)
$____________.
(average amount of bonus)
7.
I do/do not (circle one) have health insurance available for the child(ren)
through my employment at a cost of $_____________________ per month.
(cost of coverage for child(ren) only)
8. My spouse does/does not (circle one) have health insurance available for the
child(ren) through employment at a cost of $_____________________ per
(cost of coverage for childr(en) only)
month.
Continued on next page …
Financial Affidavit for Child Support, DC 6:5(2), PSC Nebraska.
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