Child Support Obligation Income Statement Affidavit
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1
2State of Alabama
Case Number
CHILD-SUPPORT-OBLIGATION
Unified Judicial System
INCOME STATEMENT/AFFIDAVIT
Form CS-41
Rev. 1/09
IN THE ____________________________ COURT OF __________________COUNTY, ALABAMA
(Circuit or District)
(Name of County)
Plaintiff _____________________________ v.
Defendant _________________________________
AFFIDAVIT
I, ____________________________________________, being duly sworn upon my oath, state as follows :
(Name of Affiant)
1. I am the
Plaintiff
Defendant
Other (please specify):_________________ in the above matter.
My Social Security number is:_____________________________________
2. I am
currently employed. My employer’s name and address are:
_____________________________________________________________________
_____________________________________________________________________
not currently employed.
My last employer’s name and address are: _______________________________________
_________________________________________________________________________
Last position title: __________________________________________________________
Average monthly salary in the last year of employment: $ ___________________________
3. My monthly gross income includes:
(For example of income that must be included, see back of this form. If income varies by month, enter the estimated average monthly gross income.)
Employment income
$______________________________
Self-employment income
$______________________________
Other employment-related income
$______________________________
Other non-employment-related income
$______________________________
Total
$_______________________________
4. I incur the following amount monthly for work-related
child-care:
$______________________________
(if none, write “None”)
5. 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”)
6. I pay the following total amount for
child support
alimony in (a) prior
case(s) as follows:
(List case number(s) and county(ies) and state(s) here):
__________________________________________
$______________________________
(if none, write “None”)
__________________________________________
I understand that I will be required to maintain all income documentation used in preparing this Income Statement/Affidavit (including
my most recent income-tax return) and that such documentation shall be made available as directed by the court. I also understand
that any intentional falsification of the information presented in this Income Statement/Affidavit may subject me to the penalties of
perjury.
______________________________________________
Affiant
Sworn to and subscribed before me this ______
day of _______________________, ________
______________________________________
Notary/Clerk
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