Form Cs404 6A – Fill Out and Use This PDF

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.

If you are married and file taxes jointly, please provide your current spouse's annual income so that tax credits may be calculated accurately. $

List all schools attended following high school. Include training school, college or university, trade school.

B. CHILDREN

1. List all of your natural and adopted children (do not include stepchildren)

2.Complete the table below for all expenses you pay and benefits you receive on behalf of all children shown in the previous table. Attach proof for the items listed below. Do NOT list amounts paid by other parent.

* For example - Social Security Benefits

**The majority of a 24 hour period the children are in your control

*** Do not include lodging, food and entertainment

4.If any of the children listed above have ongoing medical expenses, please describe.

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:

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C. EMPLOYMENT

1.List your current or most recent employer(s) first and your past two employers:

2.What kinds of work do you/did you do for your employer(s)?

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 disability, that prevents you from being able to work full-time or from being able to earn

statement from your doctor or the Social Security Administration

If yes, describe your job search:

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D. INCOME

1. List all income which you receive or have received in the last 12 months.

2. Do you receive any non-cash benefits from your employer, such as housing, groceries, meat, car or truck, utilities,

If yes, describe the non-cash benefit you receive, how often you receive it, and the value of the benefit:

3. If you are self-employed, describe your self-employment activities:

How many hours per week do you spend engaged in self-employment activities?

5.ATTACH COPIES OF YOUR PAY STUBS 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

1.List deductions from gross wages, including costs for required uniforms or work related equipment. Attach pay stubs and proof of expenses.

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3. Do you have any extraordinary medical expenses for yourself, not reimbursed by insurance, your employer, or

If yes, list yearly expenses and attach proof:

4.Please list any necessary expense you pay for in-home nursing care to enable you to work and for whom the expense is paid:

6.List employment related expenses not shown elsewhere:

8. Please attach a list of monthly expenses if you feel it is important to show your financial situation.

F.ANTICIPATED CHANGES / ADDITIONAL COMMENTS

1.Please list any changes you expect in your or your child(ren)'s circumstances during the next 18 months which would affect the calculation of child support?

2.Additional Comments (a separate sheet may be attached):

VERIFICATION: You must sign this in front of a Notary Public.

STATE OF

COUNTY OF

I declare, subject to penalties for perjury and false swearing, that I have read the foregoing affidavit and that the information contained in it and all attachments to it is true and correct to the best of my knowledge, information and belief.

Signed and sworn before me, a Notary Public for this State, on the date and at the place written above.

NOTARY PUBLIC

(SEAL)Print Name: Residing at:

My Commission Expires:

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