MONTANA CHILD SUPPORT GUIDELINES FINANCIAL AFFIDAVIT
If you want to determine the cost of a child under 18 years old to calculate how much money will have to be paid for child support, you have to complete and submit the Montana Child Support Guidelines Financial Affidavit.
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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. 2 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: 3 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
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