Financial Affidavit

FINANCIAL AFFIDAVIT

This affidavit is for the purpose of computing the child support obligation for your child(ren). If you are the obligor, your cooperation in completing it and returning

it to us will keep us from having to take legal action to compel you to provide this information. Please print or type your answers and have the affidavit notarized

and return it to the Child Support Enforcement Division office address listed on the attached letter.

PERSONAL DATA

Your Full Name - First MI. Last / Date of Birth / Social Security Number
Your Present Address - Number and Street/Post Office Box/Rural Route / Your Daytime Phone Number
City, State Zip Code / Your Message Phone Number

Do you have any minor children (not including stepchildren) for whom you are legally responsible but who are not included in this order? If so please give their

names and their dates of birth:

NAME OF MINOR CHILDREN

/ DATE / OF / BIRTH

In order for you to receive credit for these children in the support calculation, you must attach a copy of the child's birth certificate or adoption certificate for children

who are living with you, or a copy of a court order showing your legal obligation for children who are not living with you. Please note that we are asking for these

documents only for children who are not included in this support order.

Do you pay alimony (spousal maintenance) to anyone? If so, how much: $ per month. (Please attach proof of payment).

INCOME AND ASSET INFORMATION

Your current or most recent employer's name / Employer's phone number
Employer's Address - Number & Street/Post Office Box/Rural Route
City, State, Zip Code

Date employment began: or, if a former employer, dates employment began and ended:

Monthly Gross Income (before taxes and deductions) / How often do you get paid?
$ / Gross amount per paycheck: (Before taxes and deductions)
Hourly rate: $ / How many hours do you work each week?
Weekly Rate: $ / Do you receive a commission or tips?
Monthly Rate: $ / If so, how much and how often?
Annual Rate:$ / Attach consecutive wage stubs for the last three months you've worked and a copy of your most recent tax return including all attachments and copies of W-2 forms.

OTHER INCOME

Do you or the child(ren) included in this order receive income from any other source? (Examples: Social Security, Veteran's Benefits, Interest, Dividends, Workers' Compensation, Unemployment Compensation, Retirement)
If so, how much and how often?
Do you receive alimony (spousal maintenance) form any former spouse? If yes, how much? $ Per month

The following questions relate to the care of the child(ren) listed in the Order only.

Names of the child(ren) and the number of nights per year the children spend with you:

NAME OF CHILDREN / Number of Nights per year

Do you provide work-related child care for the child(ren) of this order? Yes  No  If yes, to whom is it paid?

How much do you pay per month for this child care? Per month. Please provide verification of child care expenses, such as copies of cancelled checks

or receipts.

Do you provide health insurance for the child(ren) of this order? Yes  No 

What is the cost of insurance? $ How many people are covered by this policy?

Name of Insurer: Insurer's phone number:
Address of Insurer: (Number, Street, Post Office Box, Rural Route)
City, State, Zip Code
:
Individual Policy Number: Group Policy Number:

If you do provide insurance coverage, please provide verification of monthly expense (such as a pay stub showing a deduction for medical insurance) and documentation

of the coverage provided. If you do not provide insurance coverage for the child(ren), does your employer provide a health insurance plan to employees? YES NO

Do you have extraordinary expenses for the children in this order? ("Extraordinary Expenses" include uninsured medical and dental expenses; special or private elementary

or secondary schools to meet the particular educational needs of the child; expenses for transportation of the child between the homes of the parents). If so, please explain and

give the amount:

If you claim that there are extraordinary expenses, you must provide proof of those expenses. Please attach copies of receipts.

Do you claim that there are extraordinary circumstances which should cause the child support amount to be adjusted? If so please explain, and attach copies

of any documents that show these circumstances:

I SWEAR OR AFFIRM THAT THIS INFORMATION IS COMPLETE AND TRUTHFUL TO THE BEST OF MY KNOWLEDGE, INFORMATION OR BELIEF.
Signature must be notarized: Date

SUBSCRIBED and SWORN to before me this day of

My Commission Expires:

CSED Form 532 Revised 3/00 CSED Worker ID

Sequence number