Cite as
2016 Ark. 173
SUPREME COURT OF ARKANSAS
No.
IN RE ADMINISTRATIVE Opinion Delivered April 14, 2016
ORDER NUMBER 10 –
AFFIDAVIT OF FINANCIAL
MEANS
PER CURIAM
The Supreme Court Committee on Child Support has proposed a new Affidavit of
Financial Means. The affidavit, required by Section IV of Administrative Order Number
10, has been revised and updated to provide more pertinent information to the parties and
to the courts in matters involving family support than the current affidavit. The last page
of the proposed affidavit includes two additions, an “Acknowledgement of Responsibilities
and Consequences” for the party submitting the affidavit to sign, and a signature line for the
party’s attorney to certify that he or she has “reviewed [this] affidavit with [the] client and
advised him or her of the importance of providing true, correct, complete answers and the
required exhibits.”
We are publishing the proposed affidavit for comment. Since it is essentially new,
rather than an amended document, attached are both the proposed and the current affidavits,
the latter lined-out to indicate that the Committee recommends the entire document be
deleted and replaced with the new affidavit. Comments may be made in writing before
May 20, 2016, to Stacey Pectol, Clerk, Supreme Court of Arkansas, Attn: Administrative
Order Number 10, Justice Building, 625 Marshall Street, Little Rock, Arkansas 72201.
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 exhibit 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
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 case $
as required by page 7):
F. Court-ordered child support for 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”
If you pay support for children not involved in this case in a form other than
payroll deduction, then you should attach the child support order and proof
of payment as an exhibit 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 may 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
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 Investment 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
ANNUAL INCOME: $
OTHER AVAILABLE FUNDS
5 ASSET AMOUNT SOURCE
Cash on hand, and in bank accounts:
5.1
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
MY CURRENT MONTHLY EXPENSES *
6.
Expense: Amount: Expense: Amount:
a. Rent/house payment Health Insurance
$ n. $
b. Gas, water, trash, & Non-covered medical
$ o. $
electricity (including medicine)
c.
Telephone $ p. Life insurance $
d. Internet $ q. Car payment $
e.
Media Services, i.e. $ r. Car Insurance $
Cable/Satellite, etc.
f.
Child care $ s. Car fuel and $
maintenance
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.
Page 4 of 7
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: $ $
Page 5 of 7
9. 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
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 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 March 2016
Page 7 of 7
IN THE CIRCUIT COURT OF COUNTY, ARKANSAS
(Domestic Relations Division)
STATE OF ARKANSAS }
} AFFIDAVIT OF FINANCIAL MEANS
COUNTY OF }
Revised 12/2006
Plaintiff
V. No.
___________________
Defendant
The affiant, being duly sworn, says under penalty of perjury that affiant is the
(PLAINTIFF) (DEFENDANT) (strike out one) herein, has prepared this financial statement,
knows the contents thereof, and that it is true and correct.
MY INCOME
(Complete Block 21 on pages 4 and 5 FIRST)
1. How often are you paid? Amount
___weekly
___biweekly (26 times a year)
___monthly
___bimonthly (twice a month–24 times a year)
___other
1.a Net Pay: (Take-home) (from line 21.h.) $
1.b Allowable Deductions: (from line 21.g.) $
1.c Other Deductions: (from line 22.i.) $
2. No. of dependents, including self, claimed for tax withholding purposes:
3. Additional amount, if any, withheld for tax purposes: $
OTHER FUNDS & LIQUID ASSETS AVAILABLE TO ME
Page 1 of 7
4. Funds: Amount: Source of funds/assets:
4.1. Other funds/child support: $
4.2. Cash on hand or in banks: $
4.3. Stocks & bonds, etc.: $
THE CHILDREN
3.a. Financial responsibility of m y children: Num ber of children:
3.b. Num ber of children I have with opposing party: #
3.c. Num ber of other children I have: #
3.d. Total Num ber of children living with m e whom I support: #
3.e Full Nam e of child(ren) born or legally adopted of this m arriage: Date of Birth:
1.
2.
3.
4.
MY MONTHLY EXPENSES
4. Expense: Amount: Expense: Amount:
a. Rent/house payment $ k. Drugs $
b. Gas & electricity $ l. Life Insurance $
c. Water $ m. Auto Insurance $
d. Telephone $ n. Fire Insurance $
e. Food $ o. Transportation $
f. Clothing $ p. Other: $
g. Laundry & cleaning $ q. Other: $
h. Child care $ r. Other: $
Page 2 of 7
i. Car payment $ s Other: $
j. Medical $ t. Other: $
Total: $
A check m ark has been placed by all expenses which are not being paid currently.
CREDITORS
(Complete items 30, 31, & 32 on page 6 FIRST)
Whose Debts: Total Owed: (A) Total of Monthly payments: (B)
5. Joint Debts: $ $
6. Plaintiff’s Debts: $ $
7. Defendant’s Debts: $ $
GENERAL INFORMATION ABOUT PARTIES
(Do not guess concerning information about opposing party)
Information about: Plaintiff Defendant
8. Nam e:
9. Address:
10. SSN: (last four digits)
11. Date of Birth:
12. Phone No.: (hom e)
13. Phone No.: (work)
14. Em ployer:
15. Em ployer Address:
16. Em ployer Phone #:
Page 3 of 7
17. Opposing party’s net
___weekly, ___biweekly,
___m onthly or ___bim onthly
incom e:
18. Other incom e of opposing
party:
19. Num ber of children of opposing
party:
INCOME
20. How often are you paid?
weekly biweekly bimonthly monthly other
52 times a year 26 times a year 24 times a year 12 times a year Explain
YOUR NET PAY
(Gross pay minus payroll deductions)
21. Income: Amount
21.a. Gross Wages $ xxxxxxxxxxx
per pay period:
21. Deductions per check: xxxxxxx Amount
21.b. Federal Incom e Taxes W ithheld: xxxxxxx $
21.c. State Incom e Taxes W ithheld: xxxxxxx $
21.d. F.I.C.A., and m edicare 1 : xxxxxxx $
21.e. Health Insurance (children only) 2: xxxxxxx $
21.f. Court ordered child support3: xxxxxxx $
21.g. Total W ithheld: (b) thru (f) above: xxxxxxx $
Carry to line 1.b. on first page.
Page 4 of 7
21.h. $
Net take-home pay per pay period: (Subtract 21.g from 21.a)
21 i. 1
F.I.C.A. is Social Security; Include any railroad retirem ent in F.I.C.A. block.
2
Include the am ount you pay to cover the children only.
3
Include any court ordered child support for dependents of previous m arriages or
previously legally determ ined illegitim ate children and adopted children withheld from current
paycheck.
OTHER DEDUCTIONS FROM MY PAYCHECK
22. Item : Amount:
22.a. Union dues: $
22.b. Credit Union, thrift plan paym ents: $
22.c. Pension Benefits and stock purchase plans: $
22.d. Charitable contributions: $
22.e. Debt paym ents and/or garnishm ents: $
22.f. Life Insurance paym ents: $
22.g. Other (Identify): $
22.h. Other (Identify): $
22.i. Total W ithheld (total of 22.a. thru 22.h.) (Carry to 1.c. on page 1): $
The above deductions will not be considered as direct deductions from your gross pay.
However, they m ay affect the am ount of the child support obligation.
OTHER COURT ORDERED CHILD SUPPORT
23. Other court-ordered child support being paid other than by deduction: $
Attach child support order and proof of paym ent.
Page 5 of 7
CREDITORS & DEBTS
30. Debts in the nam es of BOTH PARTIES are:
Creditor: Total amount ow ed: M onthly paym ent:
30.1 $ $
30.2 $ $
30.3 $ $
30.4 $ $
30.5 $ $
30.6 $ $
30.7 $ $
30.8 $ $
Totals: $ $
Attach additional schedules as needed, and then total - Carry to lines 5A & 5B on page 3.
31. Debts in the nam e of only the PLAINTIFF are:
Creditor: Total amount ow ed: M onthly paym ent:
31.1 $ $
31.2 $ $
31.3 $ $
31.4 $ $
31.5 $ $
Totals: $ $
Attach additional schedules as needed, and then total - Carry to lines 6A & 6B on page 3.
32. Debts in the nam e of only the DEFENDANT are:
Creditor: Total amount ow ed: M onthly paym ent:
32.1 $ $
32.2 $ $
32.3 $ $
32.4 $ $
32.5 $ $
Page 6 of 7
Totals: $ $
Attach additional schedules as needed, and then total - Carry to lines 7A & 7B on page 3.
Dated this ___________ of ______________________, 20_________.
___________________________________________
Affiant
Subscribed and sworn to before me on this day of
, 20 .
Notary Public
My commission expires:
NOTICE
BOTH PARTIES MUST COMPLETE AND EXCHANGE THIS SEVEN-PAGE AFFIDAVIT
PRIOR TO THE TEMPORARY HEARING. BOTH PARTIES MUST SUPPLY THE
ORIGINAL NOTARIZED AFFIDAVIT TO THE COURT. THE COURT WILL PUNISH
PERJURY BY APPROPRIATE ACTION.
Page 7 of 7
