Child Support Obligation Income Statement/affidavit
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2Case Number
State of Alabama
CHILD SUPPORT OBLIGATION
Unified Judicial System
INCOME STATEMENT/AFFIDAVIT
Form CS-41
Rev.10/93
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
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