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Financial Affidavit

Through the information reflected in this affidavit, the court will be able to determine the appropriate amount of child support payment per parent. Assessment of payment is based on the official North Dakota Child Support Guidelines. Affiant must thoroughly accomplish the form and sign it in the present of a notary public. Should the affiant need extra space, s/he is free to add additional pages. Prior submission, affiant must attach all of the required documents and additional pages.Download

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1
FINANCIAL AFFIDAVIT 
 
 This affidavit  will help you present information to the  court for use in determining the correct 
amount of child support based on the North Dakota Child Support Guidelines.   Please complete this 
form and sign it in front of a Notary Public.   If you need more space, please attach additional 
pages.  Additional information ca n also be added in the Comment section at the end.  Attach all 
requested documents and addi tional pages and return to: 
              
              
              	 
 
1. PERSONAL BACKGROUND	
 
Name:             	
 
Address:            
 
City/State/Zip:           
 
  List the names and dates of birth of your biological or adopted children who live with you: 
  
Child’s name  Date of Birth 	
  
  
  
  
  	
 
List the names and dates of birth of your biologi cal or adopted children who do not live with you 
and the name of the person with whom each child lives: 
Child’s Name  Date of Birth  Lives With:

2
 
List the children you claim as exemptions on you
r federal income tax return.  If any of these 
children are not your biological or adopted children, please indicate the relationship (for example, 
stepchild).  
Child’s name  Relationship 	
  
  
  
  
  	
 
Do you alternate claiming the exemption for any  of your biological or adopted children with the 
other parent of those children?                    ________  Yes                  _\
_______  No 
If yes, list the names of the children  for whom the exemption is alternated:   
Child’s name 	
 
 
 
 
 	
 
Are any of your biological or adopted children for whom you claim an exemption qualifying 
children for purposes of the child tax credit?                   ________  Yes     \
             ________  No 
If yes, list the names of the children who are  qualifying children for purposes of the child tax 
credit:                 
Child’s name

3
Do you and the other parent in this child support
 matter have split custody of your children? 
(Split custody means that you and the other pa rent have more than one child in common and you 
and the other parent each have custody of at least one child.)       ________  Yes          ________  No 
 
Do you and the other parent in this child suppo rt matter have equal physical custody of your 
children? (Equal physical custody means each parent,  by court order, has physical custody of the 
children exactly fifty percent of the time.)             ________  Yes                  ________  No 
 
Does a court order specify when you have  visitation with your children?    
________  Yes       ________  No      If yes, according to the court order, is the number of nights 
any of your children spend with you: 
    More than 69 of 90 consecutive nights?        ________  Yes                  ________  No 
    More than an annual total of 164 nights?      ________  Yes                  ________  No 
If you answered yes to either of the last two questions, please provide the total number of court-
ordered visitation night per child, per year:   
Child’s name  Total number of visitation  
nights per year 	
  
  
  
  	
 
Do the children in this child  support matter receive any governme ntal or other benefits on your 
account? (Examples include dependent’s benefits from the Social  Security Administration based 
on your disability or retirement.)                   ________  Yes                  ________  No 
If yes, list the names of the children, the type  of benefit they are receiving, and the monthly 
amount of such benefit. 
Child’s Name  Type of benefit Monthly Amount

4
2. EMPLOYMENT	
 
If you are working full-time (a t least 40 hours per week) for at  least one employer, earning 
at least minimum wage ($5.15 per hour), and have  not changed jobs resulting in a reduction of 
income within the past three years, please attach a copy of you r most recent federal income tax 
return.  Include copies of all  W-2 forms, 1099 forms, and schedules .  Also, include copies of pay 
stubs showing your year-to-date income. 
  If you are only working part-time for one  or more employers, earning less than minimum 
wage, or have changed jobs resulting in a reduction  of income within the past three years, please 
attach copies of your last three fe deral income tax returns.  Include copies of all W-2 forms, 1099 
forms, and schedules.  Also, incl ude copies of your pay stubs showing year-to-date income from 
each employer. 
  For confidentiality reasons, black out all so cial security numbers and financial account 
numbers that appear on the tax forms and pay stubs you are attaching. 
  If you do have more than one employer, answ er the questions in this section based on your 
primary job.  Then attach additional pages to provide the same kind of  information for each of 
your other jobs. 
 Employer Name:             	
 
 Employer Address:             
 
 Employer City, State, Zip:            
 
  Date you started working for this employer:              
 
 Occupation:              
 
 
Hourly  $  Per hour   Hours per week 	
Monthly $  Per month  
Annually $  per year   
 
Number of pay 
periods (check one)   	
 Weekly 
 
24 per year (paid twice per month) 
 26 per year (paid every two weeks) 
 Monthly 
 Other

5
Overtime:   
Average number of overtime hours worked  per week during the past 12 months:    	
 
Rate of pay for overtime hours:   $    	
 
Commission and tips: 
  Commissions:   $     	
  per      	 
  Tips:    $     	
  per       	 
Bonuses: 
  Please provide information about the type a nd amount of any bonuses you have received in 
 the past 12 months:             	
 
              
 
              
 
              
 
Employee benefits: 
  Describe the benefits provided to you by  your employer and the annual value of such  
  benefit (examples may include paid vacation  and sick leave, health insurance, employer 
 retirement contributions, etc.)  
Benefit provide  Annual value 	
  
  
  
Total Value   	
 
In-kind Income: 
Describe any in-kind income provided to you  by your employer and the annual value of 
such income. (In-kind income means you are allowed to  use your employer’s property or 
you are being provided with services at no  charge or less than the customary charge.  
Examples include the use of living quarters , and being provided with transportation, 
groceries, or utilities.) 
  
In-kind income received  Annual value 	
  
  
Total Value

6
Union dues:      
$          	
per month 
 Name of Union:           	
 
  Are union dues required as a condition of employment?      ______ Yes     _______ No       
List any professional/occupational  licenses you hold:        	
              	 
Annual professional/occupational license fee:    $       	
 
Is this fee paid or reimbursed by your employer?    	
   Yes      	   No 
Is this license required as a  condition of employment?   	
   Yes      	   No 
Are you required, as a condition of employm ent to contribute to a retirement plan? 
         	
   Yes      	   No 
If yes, monthly amount of  required contribution:  $     	
 
 
Employee Expenses:	
 
Do you have out-of-pocket expenses for special e quipment or clothing required as a condition of 
your employment?     	
   Yes      	   No 
  If yes, are you reimbursed for these expenses?     	
   Yes      	   No 
  If no, what are your annual out-of-pock et expenses for these items?  $     	
 
Do you have out-of-pocket expenses for lodging  when you must travel as a condition of your 
employment?    	
   Yes      	   No 
  If yes, are you reimbursed for these lodging expenses   	
   Yes      	   No 
  If no, please provide the number of ov ernights in the last calendar year:    
 
  and this year to date:     	
  
 
3.     HEALTH INSURANCE AND MEDICAL EXPENSES	
 
Do you have access to dependant health insurance coverage?    	
   Yes      	   No 
  If yes, please provide the following information: 
    Are you enrolled in the health insurance plan?   	
   Yes      	   No 
    If you are enrolled in the plan, please  provide the names of persons, including  
    yourself, covered under the plan: ______________________  ______________\
______ 
    _________________________       ______________________   _______________\
_____ 
  Name of policyholder:

7
Cost for health insurance is (compl
ete all options that are available): 
  
Single plan  $ per  	
Single + dependant plan  $ per  
Family plan  $ per  	
 
Annual amount of out-of-pocket medical expenses you pay for the  children in this child support 
matter to the extent those expenses are likely to continue:   
Child’s Name  Annual amount 	
 $ 
 $ 
 $ 
 $ 
Total amount   	
 
4.    UNEMPLOYMENT	
 
If you are currently unemployed, please provid e the following information about your last 
employment.  Also, please attach copies of your  last three federal income tax returns.  Include 
copies of all W-2 forms, 1099 forms, and schedules.   For confidentiality reasons, 	
 black our all 
social security numbers and financial account numbers that appear on the tax forms you are 
attaching.  Reason for unemployment:           	
 
Date you became unemployed:           
 
Name of last employer:           
 
 Employer Address:             
 
 Employer City, State, Zip:            
 
 Occupation:              
 
Wages for last employment (complete the opti on that best described your situation) 
Hourly  $  Per hour   Hours per week 	
Monthly $  Per month  
Annually $  per year

8
Number of pay periods 
for last employment 
(check one) 
 	
 Weekly 
 
24 per year (paid twice per month) 
 26 per year (paid every two weeks) 
 Monthly 
 Other   	
 
 
Overtime:   
Average number of overtime hours worked per w eek during the final  past 12 months of  
your last employment   $     	
 
Rate of pay for overtime hours:   $    	
 
Commission and tips for last employment: 
  Commissions:   $     	
  per      	 
  Tips:    $     	
  per       	 
Bonuses: 
  Please provide information about the type  and amount of any bonuses you received during 
  the final 12 months of your last employment:               	
 
              
 
              
 
              
 
 
Did you receive severance pay when you  became unemployed?      	
   Yes      	   No 
  If yes, amount received:  $     	
 
 
5.    SELF-EMPLOYMENT	
 
If you are self-employed, please attach copies  of your personal and business federal income tax 
returns for the past five years.  Thes e include IRS forms 1040, 1065, 1120, and 1120S, as well 
as all related schedules.   For confidentiality reasons, 	
black out all social security numbers and 
financial account numbers that appear on the tax forms you are attaching.

9
If you have more than one self-employment activi
ty, answer the questions in this section based 
on your primary activity.  Then attach additional pages to provide  the same kind of 
information for each of  your other activities. 
 
  STRUCTURE OF BUSINE SS ENTITY  PERCENTAGE	
 Sole proprietorship   
 Partnership; percent ownership interest:   
 Limited liability company; percent ownership interest:   
 S Corporation; percent ownership interest   
 C Corporation; percent ownership interest   
 
      Name of business entity:                    	
 
      Address:              
 
      City/State/Zip:            
 
       
 TYPE  OF BUSINESS 	
 Farming/Ranching 
 Service 
 Retail Sales 
 Wholesale Sales 
  Other (please described) 	
 
Description of business activity (e.g., type of  service provided, type of item(s) sold, etc. 
              	
 
              	
              
              	 
      
How long has this business been in existence?           	
  Years   	   Months

10
Names of household members who work in this business, the wage/salary paid to the household 
member, and household member’s job duties: 
Household member’s name	
 	Wage/Salary	 	Job Duties	 	
   
   
   
 
6.    OTHER INCOME	
   
Workers’ compensation Benefits  $ per  	
Social security disability  $ per  
Social security retirement  $ per  
Dividends and interest  $ per  
Railroad retirement  $ per  
Veterans’ benefits  $ per  
Other pension or retirement benefits  $ per  
Trust income  $ per  
Unemployment compensation  $ per  
Gifts and prizes of more than $1,000/year  $ per  
Refundable tax credits  $   
Gains $    
Spousal support (alimony) payments received  $ per  
Military subsistence payments received  $ per  
Rental income  $ per  
Other (specify)  $ per  	
 
7.    COMMENTS	
 
Please use this section to provide any other in formation that you feel would help the court 
understand the situation:

11
8.     SIGNATURE	
 
 
I state, under penalty of perjury, that the in formation contain in, and attached to, this 
Financial Affidavit, is true and co rrect to the best of my knowledge. 
 
Date:     	
 Signature:       	 
 
State of      	
 
 
County of     
 
 
Subscribed and sworn to before on       , 	
 20   .	 
 
   (Seal)            	
 
           	
 Notary Public 
      My commission expires:
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