Cite as 2016 Ark. 315 SUPREME COURT OF ARKANSAS Opinion Delivered September 15, 2016 IN RE SUPREME COURT COMMITTEE ON CHILD SUPPORT—AFFIDAVIT OF FINANCIAL MEANS PER CURIAM 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 Case No. DR Defendant 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 Signature Subscribed and sworn to before me on this day of 20 - 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 exhiþit if necessary) 2.* Net Pay: (Take-home after allowable deductions) $ *Complete worksheet on next page to determine Net Pay for calculating child support Page 1 of 7 Ini t iaf s Ini t iaf s
NET PAY WORKSHEET (lf 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 lncome Taxes Withheld $ B. State lncome Taxes Withheld $ C. F.l.C.A. (Social Security) or Railroad Retirement $ D. Medicare: $ E. Health lnsurance (only the porlion paid for children in fhis case $ as required by page 7) F. Court-ordered child supportfor other children not $ involved in this current case. (For example, children from a 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" lf you pay support for children nof involved in this case in a form other than þavro ll deduction , then you should attach the ch¡ld support order and proof of ment as an exh¡b¡t to this affidavit Any other deductions from your paycheck do not figure into your net pay under Arkansas law regarding child support. Some examples of payroll deductions that you mav not subtract from your income for calculating child support include: pension plans, union dues, 401(k) payments, loan repayments, charitable contributions, life insurance, and health insurance payments that cover you or your spouse. However, the court may consider these expenses, particularly if they are significant, so you should reflect them in the proper place in the pages to follow' Page 2 of 7 Ini t ial- s Initials
OTHER INCOME Other income Amount: Source Frequency 4 Bonuses or incentive pay not 4.1 reflected on page 2: 4.2 Other court-ordered income such as alimony/child support paid to you: 4.3 Payments from a settlement or annuity: 4.4 Regular gifts from relatives or friends: 4.5 lnvestment income such as rent payments to you: 4.6 Stock dividends or bond payments: 4.7 Regular payments to you or on your behalf from a Trust: 4.8 Other: 4.9 TOTAL OTHER INCOME: $ OTHER AVAILABLE FUNDS 5 ASSET AMOUNT SOURCE Cash on hand, and in bank 5.1 accounts: 5.2 Trust fund assets held on your behalf: 5.3 Stocks, bonds, mutual funds 5.4 Other (i.e. 401-K, retirement, etc) 5.5 TOTAL: $ Page 3 of 7 rni t ia1 s rni t iaÌ s
MY CURRENT MONTHLY EXPENSES * 6 Expense: Amount: Expense: Amount: a Rent/house payment $ n Health lnsurance $ b Gas, water, trash, & $ o Non-covered medical $ electricity (including medicine) c. Telephone $ p Life insurance $ d lnternet $ q Car payment $ e Media Services, i.e $ r Car lnsurance $ ,Cable/Satellite, etc. f Child care $ S Car fuel and $ maintenance g Food $ t Lawn care $ h Union dues $ u Charitable giving $ Pension plan $ V Household Expenses $ 401(k) payments $ W Dry cleaning $ J k. Garnishments $ X Other $ Cigarettes $ v Other: $ m Alcohol $ z. $ TOTAL * Place a check mark by all expenses which you are not currently paying. Page 4 of 7 Tni t ia1 s Ini t i-al- s
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 I 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: $ $ Page 5 of 7 Ini t iaI s lni t iaI s
L Debts only in my name: Creditor: Total amount owed: Monthly payment a $ $ b $ $ c $ $ d $ $ e $ $ Totals $ $ '10. Debts only in the name of the other party: Creditor: Total amount owed Monthly payment: a $ $ b $ $ c $ $ d $ $ e $ $ Totals $ $ 11. SUMMARY OF ABOVE DEBT TABLES Summary of Debts: Total Owed: Total Monthly Payments: a Joint Debts: $ $ b My Debts: $ $ c Other Party's Debts: $ $ Page 6 of 7 Ini t ial- s Ini t ial- s
ACKNOWLEDGEMENT OF RESPONSIBILITIES AND CONSEQUENCES l, understand that I must comply with the following, I acknowledge and agree to each provision by initialinq each paraqraph 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. lf I am employed, I must attach copies of my last three paystubs to this affidavit. lf 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 Ue¡,veen 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 cou11, being fined, being ordered to pay attorney's fees, and/or being sentenced up to 6 months in fail, and that serious violations can result in prosecution for felony perjury-punishable by 3 to '10 years in prison. Date 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 Attorney Form Revised 10 t2016 Page 7 of 7
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