Connecticut Financial Affidavit Form

Through the fulfillment of this form, the divorcing spouses learn about their exact conjugal assets, properties, and debts.Download

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MONTANA CHILD SUPPORT GUIDELINES 

FINANCIAL AFFIDAVIT
 	
INSTRUCTIONS FOR COMPLETING THIS FORM:   Provide complete information, attaching additional pages if needed.  
If a question or statement does not apply to you, DO NOT LEAVE IT  BLANK; instead, mark it as "Not Applicable" or "N/A." 
Be sure to  sign this form and have your signature notarized . 
A. PERSONAL INFORMATION  Full Name: 
Home Address: 
Mailing Address:  Work Phone No.: 
Home/Cell No.:  Date of Birth: 
Case Number: 
Driver's License No.: 
What is your tax filing status?    Single Married, joint     Married, separate     Head of Household  
List the people you claim as tax exemptions 
If you are married and file taxes jointly, please provide your  current spouse's annual income so that tax credits may be 
calculated accurately.  $ 
Did you finish high school?	
 Yes

 	
 
 	
 	
 	
 	
 	
 	
       
       
       
       
       	
 
        	
 
 
  	
  
  
 
   
  
 
 	
 
 
 
 
 
   	
  
  	
 	
   	
 	
   
      
   
   
  
 
  	
 No 	Yes  $  /month reimbursement  	
No 	Yes 
If no, skip to Section C.  If yes, to have the cost included  in your child support calculation, you must do one of the 
following before the final order is entered: 
A. Prove that you currently have insurance  coverage in effect for the children; or 
B. Obtain verification from the insurance carrier that you  have paid a premium with the intent to enroll the children. 
Name everyone who is covered by this policy:   
Regardless of whether your children are covered, complete the following: 
Insurance Co. Name: 
Address:  
Policy Number:  
Certificate Number: 
$  Total cost of health insurance premium per mo nth, including your children (whether or not you 
and the children are currently enrolled). 
$  Adult's portion of premium. 
$  Child(ren)'s portion of premium. 
$  Portion of premium to be paid by you each month. 
$  Portion of premium to be paid by employer or other group each month.  	
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C. EMPLOYMENT 	
No 	Yes  If yes, name of union local, address, and amount of monthly dues:   
4.  Are you currently a student?  	
No 	Yes  If yes, provide a copy of your  most recent registration statement 
showing tuition, fees, etc., and a copy of your most recent  financial aid award letter.  Please provide your expected 
date of graduation:   
5. 	 Is there any reason, such as disab ility, that prevents you from being able to  work full-time or from being able to earn 
income at the same level you have in the past?  	
No 	Yes  If yes, please explain and provide a  

statement from your doctor or t he Social Security Administration
 
6.  Do you receive workers' compensation or occupational disease benefits?    	
No 	
No 	
No 	Yes
 
If yes, name of state or agency paying those benefits:  

8.  If unemployed or employed part-time, have you ma de any efforts to find full-time employment?    	
No 	 Yes 
If no, why not? 
If yes, describe your job search:   	
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D. INCOME 	
No 	Yes 
4.  Have you, in the past 12 months, received any prize, award, settlement or other one-time cash payment?   	
No  Yes  If yes, describe the payment, including th e amount and its present location and value.   
5. 	 ATTACH COPIES OF YOUR PAY STUB S FOR THE LAST THREE (3) MONTHS.  ALSO ATTACH COMPLETE 
COPIES OF YOUR FEDERAL INCOME TAX RETURNS , including all schedules filed and W-2 forms, for the last 
three (3) years.  If you do not have pay stubs or W-2 forms,  provide employer's statement.  If you are self-employed, 
you must provide copies of your individual returns as well as  the business (partnership or corporation) returns for the 
last three (3) years. You may wish to black out or obscure confidential information such as social security numbers or 
financial account numbers. 
E. DEDUCTIONS AND EXPENSES

 	
 
 
  
 	
 
 
 
 
   
 
   
  	
    
   
 
 
 
     
  
      
  
  
  
  
        
   
    	
 
       
 
 
  
 
  	
    	 
 
 
  
    
 
   
     
 
 
 
 	
No 	Yes  If yes, attach copy of order and proof of payments. 
3. 	 Do you have any extraordinary medical expenses for yourself, not reimburs ed by insurance, your employer, or 	
another, which are necessary for you to maintain your health or your earning capacity?       No Yes
 
If yes, list yearly expenses and attach proof:  
	
No 	Yes 	
No 	Yes  If yes, provide a court 
order and proof of payments.  
8.  Please attach a list of monthly expenses if you feel  it is important to show your financial situation.  
F.  ANTICIPATED CHANGES / ADDITIONAL COMMENTS