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