North Carolina Financial Affidavit Form

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Financial Affidavit_

This form states the financial income and liabilities for each spouse. This form must be traded with one another in order to come to terms for the Marital Settlement Agreement.

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STATE OF NORTH CAROLINA IN THE GENERAL COURT OF JUSTICE

COUNTY DISTRICT COURT DIVISION

))

FILE NO.

Plaintiff, ))

FINANCIAL AFFIDAVIT

vs. ))

, )

Defendant. )

I, , who being duly sworn, deposes and says that the

following information is true and correct according to the best of my knowledge and belief.

ITEM 1: EMPLOYMENT AND INCOME

OCCUPATION:

EMPLOYED BY:

ADDRESS:

SOC. SEC. #:

PAY PERIOD:

RATE OF PAY:

AVERAGE GROSS MONTHLY INCOME FROM EMPLOYMENT $

Bonuses, commissions, allowances, overtime, tips and similar payment $

Business income from all sources such as self-employment, partnership, close

corporations, and/or independent contracts (gross receipts minus ordinary

and necessary expenses required to produce income) $

Disability benefits $

Workers’ Compensation $

Unemployment Compensation $

Pensions, retirement, or annuity payments $

Social Security benefits $

Spousal support received from previous marriage $

Interest and dividends $

Rental income (gross receipts minus ordinary and necessary expenses

required to produce income) $

Income from royalties, trusts, or estates $

Reimbursed expenses and in kind payments to the extent that they reduce

personal living expenses $

Gains derived from dealing in property (not including nonrecurring gains) $

Itemize any other income of a recurring nature $

TOTAL MONTHLY INCOME $

LESS DEDUCTIONS

Federal, state, and local income taxes (corrected for filing status

and actual number of withholding allowances) $

FICA or self-employment tax (annualized) $

Mandatory union dues $

Mandatory retirement $

Health insurance payments $

Court ordered support payments for the children actually paid $

TOTAL DEDUCTIONS $

ITEM 2: AVERAGE MONTHLY EXPENSES Barber/beauty parlor

Cosmetics/toiletries

HOUSEHOLD: Gifts for special holidays

Mtg. Or rent payments Other expenses:

Property taxes & insurance

Electricity

Water, garbage, & sewer

Telephone INSURANCES:

Fuel oil or natural gas Health

Repairs and maintenance Life

Lawn and pool care Other Insurance:

Pest control

Misc. household

Food and grocery items

Meals outside home OTHER EXPENSES NOT LISTED ABOVE:

Other: Dry cleaning and laundry

Affiant’s clothing

Affiant’s medical, dental,

prescriptions

AUTOMOBILE: Affiant’s beauty salon/barber

Gasoline and oil Affiant’s gifts special holidays

Repairs

Auto tags and license Pets:

Insurance Grooming

Other: Veterinarian

Membership Dues:

Professional dues

CHILDREN’S EXPENSES Social dues

Nursery or babysitting

School tuition Entertainment

School supplies Vacations

Lunch money Religious organizations

Allowance Charities

Clothing

Medical, dental,

prescriptions Miscellaneous

Vitamins

OTHER EXPENSES:

$

$$$

TOTAL ABOVE EXPENSES $

PAYMENTS TO CREDITORS:

TO WHOM: BALANCE

DUE:

MONTHLY

PAYMENTS:

TOTAL MONTHLY PAYMENTS TO CREDITORS: $

TOTAL MONTHLY EXPENSES: $

ITEM 3: ASSETS (OWNERSHIP: IF JOINT, ALLOCATE EQUALLY

Description Value Husband Wife

Cash (on hand or in banks)

Stocks / bonds / notes

Real Estate:

Home:

Automobiles:

Other personal property:

Contents of home

Jewelry

Life ins. / cash surrender value

Other Assets:

TOTAL ASSETS: $ $ $

ITEM 4: LIABILITIES

Creditor Security Balance Husband Wife

TOTAL LIABILITIES $ $ $

____________________________________

Affiant

SWORN TO and signed before me

on , .

_____________________________

NOTARY PUBLIC

My Commission Expires:

CERTIFICATE OF SERVICE

I HEREBY CERTIFY that a true and correct copy of the above Financial Affidavit has

been furnished by mail this day of , , to:

.

____________________________________

Signature