, ) ) AFFIDAVIT OF FINANCIAL STANDING ) OF VS. ) (Name) ), ) Defendant. )

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STATE OF NORTH CAROLINA COUNTY OF IREDELL IN THE GENERAL COURT OF JUSTICE DISTRICT COURT DIVISION FILE NO.:, ) Plaintiff, ) AFFIDAVIT OF FINANCIAL STANDING ) OF VS. ) (Name) ), ) Defendant. ) The Affiant, having been first duly sworn as to the truthfulness and completeness of this Affidavit, deposes and says: PART I INCOME AND DEDUCTIONS (To arrive at monthly figures, weekly income is multiplied by 4.333; every other week income is multiplied by 2.166; and twice monthly income is multiplied by 2) Gross Wages Overtime Commissions Bonuses Dividends Interest Social Security Pension or Retirement Business Profit Rent Other Income TOTAL MONTHLY GROSS INCOME Federal Income Taxes State Income Taxes Social Security Taxes Medicare Taxes Retirement Medical/Dental/Vision Ins. Life Insurance Other Deductions TOTAL MONTHLY DEDUCTIONS FROM INCOME MONTHLY NET INCOME

I am paid Weekly Every Other Week Twice a Month Monthly Other I have have not received substantially the same income for the past 12 months. Explain: I am now employed at have been employed there since. If not employed, last regular job was at there until. located at and and I worked PART II EXPENSES The average monthly financial needs and expenses for the support of myself and child(ren) born to my marriage are as follows: A. HOUSING 1. Rent 2. Mortgage (Principal & Interest) 3. Second Mortgage or Equity Line 4. Real Estate Tax 5. HOA Fees 6. Home Insurance 7. Other (explain) B. UTILITIES 1. Electricity 2. Gas / Heating Oil 3. Telephone 4. Cell Phone 5. Water 6. Cable TV / Satellite 7. Internet 8. Trash 9. Other (explain)

C. HOUSEHOLD MAINTENANCE 1. Repairs 2. Service Contracts 3. Garden & Yard Work 4. Housekeeper 5. Other (explain) D. FOOD 1. Food at home 2. Food away from home 3. School lunches 4. Other (explain) E. CLOTHING / GROOMING 1. Clothing 2. Dry Cleaning 3. Barber / Beautyshop 4. Personal Grooming Supplies & Expenses 5. Other (explain) F. TRANSPORTATION 1. Gas 2. Repair, Maintenance & Inspections 3. Drivers License & Registrations 4. Auto Insurance 5. Auto Payments 6. Other (explain)

G. HEALTH & MEDICAL 1. Medical Insurance 2. Dental Insurance 3. Vision Insurance 4. Life Insurance 5. Disability Insurance 6. Medicine & Prescription Drugs 7. Medical/ dental/vision expenses not covered by insurance including co-pays 8. Other (explain H. CHILDREN S EDUCATION / CHILD CARE 1. Children s Day Care 2. Private School Tuition 3. College Tuition 4. Children s Allowance 5. School Supplies 6. Sports Activities 7. Lessons 8. Tutoring 9. Other (explain)

I. PERSONAL / ENTERTAINMENT 1. Books, Magazines, Newspapers 2. Dues (professional & social) 3. Charities / Contributions 4. Recreation 5. Vacations / Trips 5. Special Occasion Gifts 6. Pets 7. Other (explain) J. OTHER 1. Alimony Obligations of Prior Marriage 2. Prior Child Support Obligations 3. Other (explain) TOTAL MONTHLY EXPENSES (add subtotals of A thru J) (yourself plus children)

PART III DEBTS To the best of my knowledge, the outstanding debts presently owed by this family are as follows: *Do not list any debts previously listed in Part II (Expenses) in this section 1. 2. 3. 4. 5. 6. CREDITOR S NAME RESPONSIBLE PARTY (Husband, Wife or Joint) BALANCE DUE MONTHLY PAYMENT TOTAL DEBTS TOTAL MONTHLY EXPENSES and DEBTS (add total monthly expenses for yourself & children and total monthly debts) SCHEDULE IV Disclosure of Documents I have provided the opposing party copies of the documents listed below: This the day of, 20 Sworn to and subscribed before me this day of, 20 (Signature of Affiant) NOTARY PUBLIC My Commission Expires:

CERTIFICATE OF SERVICE This is to certify that the undersigned has this day served the forgoing document on all the parties to this cause by: Depositing a copy thereof postage paid, in the United States mail to the attorney or party addressed as follows: Hand delivering a copy hereof to the attorney or party addressed as follows: Depositing a copy thereof with a nationally recognized courier service, for delivery, addressed to the attorney or party as follows: Telecopying a copy thereof to the attorney or party as follows: This day of, 20 (Signature of Affiant)

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