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Affidavit of Financial Means

If a person wishes to disclose their financial means, they have to use this affidavit in order to be able to do so.

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Page 1 of 7                             ______      ______ 
                                  	
 Initials        Initials	 
   IN THE CIRCUIT COURT OF                               COUNTY, ARKANSAS 	
                                                      	(Domestic Relations Division) 
 	
_____Division 
  
                                   _____________ 	
Plaintiff 
 
v.      Case No.   _____DR__________________ 
 
                                 _____________       	
 	
Defendant 
 
AFFIDAVIT OF FINANCIAL MEANS 	
 	
Name:_________________________, being duly sworn, says under penalty of perjury, 
that he/she has prepared or approved this financial statement, and that the following 
information and attachments (including income verification as required by page 7) 
are complete, true, and correct. 
 
__________________       _____________________________ 
Date       Signature 
 
Subscribed and sworn to before me on this      day of                          20   . 
         
                                                                  	
Notary Public 
My commission expires:                    . 	
 
 	
MY INCOME	  	 
1.  
How often are you paid? 
 
     ____ weekly 
     ____ bi-weekly (every two weeks—26 times a year) 
     ____ monthly 
     ____ bi-monthly (twice a month–24 times a year) 
     ____ other –Explain (attach an exhibit if necessary): 
2.* 	
 
Net Pay: (Take-home after allowable deductions) 
 
                                   $__________________________ 	
 
*Complete worksheet on next page to determine Net Pay for calculating child support.

Page 2 of 7                             ______      ______ 
                                  	
 Initials        Initials	 
   	
NET PAY WORKSHEET 	
(If more than one employer, fill out and attach multiple copies of this worksheet). 	
 
EMPLOYER: 	
Address:                                                     Telephone #: 
 
 
3.  Gross Wages per pay period: 	 
$ 	
ALLOWABLE DEDUCTIONS UNDER STATE LAW  ========= 
 
A.  Federal Income Taxes Withheld: 	$ 	
B.  State Income Taxes Withheld: 	$ 	
C.  F.I.C.A. (Social Security) or Railroad Retirement: 	$ 	
D.  Medicare: 	$ 	
<0028001100030003002b00480044004f0057004b0003002c005100560058005500440051004600480003000b00520051004f005c00030057004b004800030053005200550057004c00520051000300530044004c0047000300490052005500030046004b00
4c004f00470055004800510003004c00510003>this case  
     as required by page 7): 	$ 	
F.  Court-ordered child support	 for other children not  	
     involved in this current case. (For example, children from           
     a previous relationship or marriage): 	
$ 	
G.                                                     TOTAL Allowable Deductions  
  $ 	
 
 
 
3.H         Subtract TOTAL Allowable Deductions from Gross Wages  
                                                                                        = NET PAY  
 
$ 	
THE FINAL NUMBER IN THIS BOX BELONGS ON PAGE 1 UNDER “NET PAY” 
 
 	
If you pay support for children not involved in this case in a form other 
than payroll deduction, then you should attach the child support order 
<004400510047000300530055005200520049000300520049000300530044005c005000480051005700030044005600030044005100030048005b004b004c0045004c005700030057005200030057004b004c00560003004400490049004c00470044005900
4c005700110003>
 
Any other deductions from your paycheck do not figure into your net pay under Arkansas 
law  regarding  child  support.    Some  examples  of  payroll  deductions  that  you may  not 
subtract  from  your  income  for calculating  child  support  include:    pension  plans,  union 
dues,  401(k)  payments,  loan  repayments,  charitable  contributions,  life  insurance,  and 
health insurance payments that cover you or your spouse.   
 
However,  the  court may consider  these  expenses,  particularly  if  they  are  significant, so 
you should reflect them in the proper place in the pages to follow.

Page 3 of 7                             ______      ______ 
                                  	
 Initials        Initials	 
   	
OTHER INCOME 	
 
 
4 Other income:  Amount:  Source   Frequency 
 
4.1 	Bonuses or incentive pay not 
reflected on page 2: 	   	
4.2 	Other court-ordered income 
such as alimony/child support 
paid to you: 	   	
4.3 	Payments from a settlement or 
annuity: 	   	
4.4 	Regular gifts from relatives or 
friends: 	   	
4.5 	Investment income such as rent 
payments to you: 	   	
4.6 	Stock dividends or bond 
payments: 	   	
4.7 	Regular payments to you or on 
your behalf from a Trust: 	   	
4.8 	Other: 	   	
 4.9 
TOTAL OTHER 
ANNUAL INCOME: 	
$ 	
 
OTHER AVAILABLE FUNDS 
5 
ASSET AMOUNT  SOURCE 	
 
5.1 	Cash on hand, and in bank 
accounts: 	 
  
      	
5.2 	Trust fund assets held on your 
behalf: 	  
 	
5.3 	Stocks, bonds, mutual funds: 
   
 	
5.4 	Other (i.e. 401-K, retirement, etc):  	  
 	
5.5 TOTAL:  
$

Page 4 of 7                             ______      ______ 
                                  	
 Initials        Initials	 
   
 	
MY CURRENT MONTHLY EXPENSES *	 
 
6.  
        Expense:  
Amount:   
  
      Expense:  
Amount: 	
 
a. 	 
Rent/house payment 	 
$  
n. 	 
Health Insurance 	 
$ 	
 
b. 	 
Gas, water, trash, & 
electricity 	 
$  
o. 	 
Non-covered medical 
(including medicine) 	 
$ 	
 
c. 	 
Telephone 	 
$  
p. 	 
Life insurance 	 
$ 	
 
d. 	 
Internet 	 
$  
q. 	 
Car payment 	 
$ 	
 
e. 	 
Media Services, i.e. 
Cable/Satellite, etc. 	 
$  
r. 	 
Car Insurance 	 
$ 	
 
f. 	 
Child care 	 
$  
s. 	 
Car fuel and 
maintenance 	 
$ 	
 
g. 	 
Food 	 
$  
t. 	 
Lawn care 	 
$ 	
 
h. 	 
Union dues 	 
$  
u. 	 
Charitable giving 	 
$ 	
 
i. 	 
Pension plan 	 
$  
v. 	 
Household Expenses 	 
$ 	
 
j. 	 
401(k) payments 	 
$  
w. 	 
Dry cleaning 	 
$ 	
 
k. 	 
Garnishments 	 
$  
x. 	 
Other: 	 
$ 	
 
l. 	 
Cigarettes 	 
$  
y. 	 
Other: 	 
$ 	
 
m. 	 
Alcohol 	 
$  
z.  
                     
TOTAL:  
$ 	
 
* Place a check mark by all expenses which you are not currently paying.
Next: Affidavit of Right to Redeem Tax Lien Previous: Affidavit Re Real Property of Small Value ($50,000 or less)
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