Child-Support-Obligation Income Statement/Affidavit

Child Support Obligation Income Statement Affidavit.pdf This states the amount of money each spouse makes on a yearly basis as well as other major expenses. Form helps determine exact amount of child

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 State of Alabama Unified Judicial System Form CS-41 Rev.10/93  CHILD SUPPORT OBLIGATIONINCOME STATEMENT/AFFIDAVIT Case Number 
IN THE ____________________________ COURT OF __________________________COUNTY Plaintiff _____________________________ v. Defendant _________________________________ 
AFFIDAVIT ____________________________________________, being duly sworn upon my oath, state as follows :1 I am the plaintiff defendant in the above entitled matter.

My Social Security number is:_____________________________________

2 I am currently employed. My employer’s name and address is:

_____________________________________________________________________

_____________________________________________________________________

Not currently employed.

My last employer’s name and address is: ________________________________________

_________________________________________________________________________

Last position title: __________________________________________________________

Average monthly salary last year of employment: $ ________________________________

3. My gross monthly income includes:

(For example of income that must be included, see back of form. If income varies by month, enter the estimated average monthly income.) 

Employment income $______________________________

Self-employment income _______________________________

Other employment-related income _______________________________

Other non-employment related income _______________________________

Total $

_______________________________

3a. I incur the following amount monthly for child-care $______________________________

(if none, write “None”) 

3b. The child(ren) of the parties is/are

not covered by health insurance from me

and/or my employer.

Covered by health insurance and I pay the

following amount monthly for the insurance

coverage. $ ______________________________

(if none, write “None”) 

4. I understand that I will be required to maintain all income documentation used in preparing this affidavit (including my most recent income tax return) and that such documentation shall be made available as directed by the court.

5. I understand that any intentional falsification of the information presented in this income statement/affidavit shall be deemed contempt of court.

______________________________________________

Affiant

Sworn to and subscribed before me this ______

day of _______________________, 20 ______

______________________________________

Notary/Clerk/Register