Opinion
09-15-2016
IN RE SUPREME COURT COMMITTEE ON CHILD SUPPORT—AFFIDAVIT OF FINANCIAL MEANS
The Supreme Court Committee on Child Support proposed a new Affidavit of Financial Means to the court, revised and updated to provide more pertinent information to the parties and the courts in matters involving family support than the current affidavit provides. By per curiam dated April 14, 2016, the court published the proposed affidavit for written comments due to the court by May 20, 2016.
The court requested that the committee review the comments submitted and, taking those into consideration, to make a final recommendation to the court. The committee's final recommendation is to adopt the proposed affidavit with one change suggested in the comments, to add lines at the bottom of each page for the litigants and, if represented, their attorneys, to initial.
The court accepts the committee's recommendation and adopts the new affidavit, with that one change, effective October 10, 2016. The new Affidavit is attached.
IN THE CIRCUIT COURT OF __________ COUNTY, ARKANSAS
(Domestic Relations Division)
___Division
__________ Plaintiff v. __________ Defendant Case No. ___DR__________
AFFIDAVIT OF FINANCIAL MEANS
Name:__________, being duly sworn, says under penalty of perjury, that he/she has prepared or approved this financial statement, and that the following information and attachments (including income verification as required by page 7) are complete, true, and correct. __________
Date /s/_________
Signature Subscribed and sworn to before me on this ___ day of __________ 20___. /s/_________
Notary Public My commission expires: __________.
MY INCOME
| 1. | How often are you paid?___ weekly___ bi-weekly (every two weeks—26 times a year)___ monthly___ bi-monthly (twice a month-24 times a year)___ other -Explain (attach an exhibit if necessary): |
| Net Pay: (Take-home after allowable deductions)$__________ |
|---|
NET PAY WORKSHEET
(If more than one employer, fill out and attach multiple copies of this worksheet).
| EMPLOYER:Address: Telephone #: | |
| 3. Gross Wages per pay period: | $ |
| ALLOWABLE DEDUCTIONS UNDER STATE LAW | ========= |
| A. Federal Income Taxes Withheld: | $ |
| B. State Income Taxes Withheld: | $ |
| C. F.I.C.A. (Social Security) or Railroad Retirement: | $ |
| D. Medicare: | $ |
| E. Health Insurance (only the portion paid for children in this caseas required by page 7): | $ |
|---|---|
| F. Court-ordered child support for other children notinvolved in this current case. (For example, children froma previous relationship or marriage): | $ |
| G. TOTAL Allowable Deductions | $ |
| 3.H Subtract TOTAL Allowable Deductions from Gross Wages= NET PAY | $ |
|---|
THE FINAL NUMBER IN THIS BOX BELONGS ON PAGE 1 UNDER "NET PAY"
| If you pay support for children not involved in this case in a form otherthan payroll deduction, then you should attach the child support orderand proof of payment as an exhibit to this affidavit. |
|---|
OTHER INCOME
| 4 | Other income: | Amount: | Source | Frequency |
| 4.1 | Bonuses or incentive pay notreflected on page 2: | |||
| 4.2 | Other court-ordered incomesuch as alimony/child supportpaid to you: | |||
| 4.3 | Payments from a settlement orannuity: | |||
| 4.4 | Regular gifts from relatives orfriends: | |||
| 4.5 | Investment income such as rentpayments to you: | |||
| 4.6 | Stock dividends or bondpayments: | |||
| 4.7 | Regular payments to you or onyour behalf from a Trust: | |||
| 4.8 | Other: | |||
| 4.9 | TOTAL OTHERANNUAL INCOME: | $ |
|---|
OTHER AVAILABLE FUNDS
| 5 | ASSET | AMOUNT | SOURCE |
| 5.1 | Cash on hand, and in bankaccounts: | ||
| 5.2 | Trust fund assets held on yourbehalf: | ||
| 5.3 | Stocks, bonds, mutual funds: | ||
| 5.4 | Other (i.e. 401-K, retirement, etc): | ||
| 5.5 | TOTAL: | $ |
|---|
MY CURRENT MONTHLY EXPENSES
| 6. | Expense: | Amount: | Expense: | Amount: | |
| a. | Rent/house payment | $ | n. | Health Insurance | $ |
| b. | Gas, water, trash, &electricity | $ | o. | Non-covered medical(including medicine) | $ |
| c. | Telephone | $ | p. | Life insurance | $ |
| d. | Internet | $ | q. | Car payment | $ |
| e. | Media Services, i.e.Cable/Satellite, etc. | $ | r. | Car Insurance | $ |
| f. | Child care | $ | s. | Car fuel andmaintenance | $ |
| g. | Food | $ | t. | Lawn care | $ |
| h. | Union dues | $ | u. | Charitable giving | $ |
| i. | Pension plan | $ | v. | Household Expenses | $ |
| j. | 401(k) payments | $ | w. | Dry cleaning | $ |
| k. | Garnishments | $ | x. | Other: | $ |
| l. | Cigarettes | $ | y. | Other: | $ |
| m. | Alcohol | $ | z. | TOTAL: | $ |
Place a check mark by all expenses which you are not currently paying.
MINOR CHILDREN
| 7. | Number of children: | |
| a. | Number of minor children I have with opposing party: | # |
|---|---|---|
| b. | Number of other minor children I have: | # |
| c. | Names of minor children involved in this case: | AGE |
| 1. | ||
| 2. | ||
| 3. | ||
| 4. |
CREDITORS & DEBTS
8. Debts in the names of BOTH PARTIES are:
| Creditor: | Total amount owed: | Monthly payment: | |
|---|---|---|---|
| a. | $ | $ | |
| b. | $ | $ | |
| c. | $ | $ | |
| d. | $ | $ | |
| e. | $ | $ | |
| f. | $ | $ | |
| g. | $ | $ | |
| Totals: | $ | $ |
| Creditor: | Total amount owed: | Monthly payment: | |
|---|---|---|---|
| a. | $ | $ | |
| b. | $ | $ | |
| c. | $ | $ | |
| d. | $ | $ | |
| e. | $ | $ | |
| Totals: | $ | $ |
| Creditor: | Total amount owed: | Monthly payment: | |
|---|---|---|---|
| a. | $ | $ | |
| b. | $ | $ | |
| c. | $ | $ | |
| d. | $ | $ | |
| e. | $ | $ | |
| Totals: | $ | $ |
| Summary of Debts: | Total Owed: | Total Monthly Payments: | |
|---|---|---|---|
| a. | Joint Debts: | $ | $ |
| b. | My Debts: | $ | $ |
| c. | Other Party's Debts: | $ | $ |
ACKNOWLEDGEMENT OF
RESPONSIBILITIES AND CONSEQUENCES
I, __________understand that I must comply with the following. I acknowledge and agree to each provision by initialing each paragraph below. ___Both parties must complete and exchange this seven-page affidavit by providing to opposing counsel or pro se litigants within five days before hearing. ___Both parties must supply the original notarized affidavit to the court. ___ If I am employed, I must attach copies of my last three paystubs to this affidavit. ___ If I am self-employed, I must attach copies of my last two federal and state tax returns, including all schedules, to this affidavit. ___ Before each court hearing where financial matters are at issue, I will review this document and provide updated information to the other party and to the court. ___ I understand that the cost of dependent health insurance coverage is the difference between self-only and self with dependents or family coverage or the cost of adding the child(ren) to existing coverage. ___ I understand that failing to comply with these provisions, or deliberately attempting to mislead the court or the opposing party, may result in my being held in contempt of court, being fined, being ordered to pay attorney's fees, and/or being sentenced up to 6 months in jail, and that serious violations can result in prosecution for felony perjury—punishable by 3 to 10 years in prison. __________
Date /s/ _________
Signature I certify that I have reviewed this affidavit with my client and advised him or her of the importance of providing true, correct, complete answers and the required exhibits. __________
Date /s/ _________
Attorney Form Revised 10/2016