Fillable APPENDIX 23.0B (Louisiana Supreme Court)

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APPENDIX 23.0B (Louisiana Supreme Court)

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Page ___ of ___
APPENDIX 23.0B FAMILY LAW AFFIDAVIT
_____________________________________ _____________ JUDICIAL DISTRICT COURT
Plaintiff
VERSUS DOCKET NO. __________________________
_____________________________________ ____________________ PARISH, LOUISIANA
Defendant
FILED: ________________________________ ______________________________________
DEPUTY CLERK
FAMILY LAW AFFIDAVIT
DISCLAIMER: This form is a simply a tool for mathematical calculation. Any results determined
from use of this form are not necessarily an accurate indication of what the child support should be.
Setting of child support is within the sound discretion of the judge.
Also, this form contains embedded formulas that, if modified, may corrupt the form. Be sure to
double-check all work.
YOUR INFORMATION – NOTE:
The following information is to be provided unless there is an
Order of Protection in effect ordering your address be confidential, or if you have executed an affidavit
or pleading under oath alleging you or your child’s health, safety, or liberty would be jeopardized by
disclosing identifying information. If either of the above applies, please attach the Order of Protection
or affidavit. See La. R.S. 13:1821.
Full Name:
Street Address: Telephone:
City, State, Zip:
Fax:
Mailing Address (If Different)
YOUR ATTORNEY’S INFORMATION (IF YOU ARE REPRESENTED)
Full Name:
Mailing Address:
Telephone:
City, State, Zip:
Fax:
Instructions: This form contains several sections, I-VIII. You shall by order of the court, fully complete
ALL sections that apply to your case. Check the boxes below to indicate all sections you have completed
and attached. Remove all pages that do not apply to your case before submission. Fill in the page
number blanks at the bottom of the pages you are submitting.
I.
❑
Child Custody and Visitation Matters
❑
A. Custody/Visitation by a Parent
❑
B. Custody or Visitation by a Non-Parent
❑
C. Relocation of a Child’s Residence more
than 75 miles or out-of-state.
II.
❑
Child Support and/or Spousal Support
❑
A. Child Support
❑
B. Spousal Support
III.
❑
Use of Family Home/Community Movables
IV.
❑
Injunctions
V.
❑
Contempt of Court – Child or Spousal
Support Matters
VI.
❑
Contempt of Court – All Matters except
Support
VII.
❑
Motion To Compel Discovery
VIII.
❑
Income and Expense Sheet (Required for
every case involving child support, spousal
support, or contempt involving support
matters or monetary payments)
Page ___ of ___
I. CHILD CUSTODY AND VISITATION MATTERS
This section is to be completed in all cases involving child custody and visitation unless there is an Order
of Protection in effect ordering your address be confidential, or if you have executed an affidavit or
pleading under oath alleging you or your child’s health, safety, or liberty would be jeopardized by
disclosing identifying information. If either of the above applies, please attach the Order of Protection or
affidavit. See La. R.S. 13:1821.
GENDER CURRENT AGE DATE OF BIRTH
Where and with whom do the children live currently?
1. List all parishes/counties and states where the children have lived in the past five (5) years
PARISH/COUNTY STATE OR COUNTRY
WHEN CHILDREN LIVED
THERE (DATES)
2. List all persons other than you with whom the children have lived in the past five (5) years
NAME
ADDRESS
RELATIONSHIP
3. Have the children ever been involved in any of these cases? ❑ Yes ❑ No
If the answer is yes, please check below:
❑ Divorce/Separation ❑ Paternity ❑ Juvenile Court ❑ Paternal Rights Termination
❑ Custody/Visitation ❑ Protective Order ❑ Child Protection ❑ Adoption
❑ Child Support ❑ Restraining Order ❑ Abuse/Neglect ❑ Other_______________
4. If you checked yes to #3 above, answer the following:
A. Name of Children:
B. Type of case (custody, visitation, paternity, OCS, protective order, etc.)
C. Court, Parish/County and State: Docket #:
Is the case still open/ongoing?
❑
Yes
❑ No
If it is a foreign judgment (from another state), has it been registered in accordance with La. R.S. 13:1801, et
seq.?
❑
Yes
❑
No
If you know of any person NOT a party to this case who has physical custody or claims to have
custody/visitation rights to a child listed above, please provide the following:
Name:
Address:
Telephone Number:
Page ___ of ___
A. CUSTODY / VISITATION BY A PARENT
1. INFORMATION ON PARENTS
What is your relationship to the children?
Who is the children’s other parent?
Were you married to the other parent at the time of the children’s birth? ❑ Yes ❑ No
If the answer to the last question is no, and you are the father, have you signed an Act of Acknowledgement?
❑ Yes ❑ No
Are you listed on the birth certificate? ❑ Yes ❑ No
Is there a Judgment of Paternity? ❑ Yes ❑ No
Please give details:
Is paternity contested? ❑ Yes ❑ No
OTHER CASES BETWEEN THE SAME PARTIES (including
Support Enforcement and Protective Orders)
Docket
Number
JDC/Parish/City
Court
NAMES OF YOUR OTHER CHILDREN NOT
AT ISSUE IN THIS CASE
GENDER
CURRENT
AGE
DATE OF BIRTH
What type of custody do you have with these children?
Who is the primary domiciliary parent?
What is your custody/visitation schedule with these children?
Do you have any restrictions or conditions on your custody or visitation? ❑ Yes ❑ No
If so, please list and attach copy of the judgment.
2. INITIAL PHYSICAL CUSTODY / VISITATION DETERMINATION
This section is to be completed only if this is an initial determination of custody or visitation.
Is there a temporary custody or visitation
court order in effect? ❑ Yes ❑ No
Provide details of any temporary order regarding custody and
visitation, with restrictions and conditions, if any.
AREAS OF DISPUTE BEFORE THE COURT. Please check those that apply.
❑ Type of custody (joint custody vs.
sole custody)
❑ Amount of time the children are with each parent (physical
custody/visitation
schedule)
❑ Who should be named as “domiciliary
parent?
❑ Conditions of physical custody or visitation (restrictions,
supervision)
Page ___ of ___
With whom do the children presently live? How long? Why are they living with this parent?
Who has been the children’s primary caretaker? (provide details if necessary)
What type of physical custody/visitation arrangement for the other parent is in the children’s best interest in
your opinion?
Is shared (about equal) physical custody possible? ❑ Yes ❑ No
Why or why not?
If you seek sole custody, briefly state the reasons (please note that joint custody is presumed to be in the best
interest of the children, and the party seeking sole custody has the burden of rebutting the presumption in
favor of joint custody by clear and convincing evidence):
If you have asked, in pleadings already filed with the court, that the other parent’s physical
custody/visitation privileges should be supervised or should have special conditions or restrictions, please
explain the factual basis for the request.
Do you claim that the other parent has physically or sexually abused you or the children? ❑ Yes ❑ No
If so, has a judge or the Department of Children and Family Services found abuse before? ❑ Yes ❑ No
If so, give details.
Has a mental health, custody or substance abuse evaluation been requested in pleadings filed with the court?
❑ Yes ❑ No
If so, list facts which support the request.
Are you willing to participate in mediation? ❑ Yes ❑ No
(If physical abuse is an issue, parties are not required to mediate.)
What is your usual and customary work schedule, holiday and vacation schedule?
Page ___ of ___
What is the usual and customary work schedule, holiday and vacation schedule of the other parent?
3. MODIFICATION OF PHYSICAL CUSTODY/VISITATION
This section is to be completed only if there has been a previous final judgment of physical custody or
visitation.
What was the date of the last
custody/visitation judgment?
Was this judgment a result of a judge trial or by the consent of the
parties (consent judgment)?
Give details of the previous judgment on custody and visitation, with restrictions listed, if any.
If the judgment was a considered decree (after a judge trial), what have you claimed in your pleadings are the
material facts affecting custody that have changed since the last judgment?
Is a temporary order in effect? ❑ Yes ❑ No
If the answer is yes, please give details.
Areas of dispute before the court. Please check those that apply.
❑ Type of custody (joint custody vs. sole
custody)
❑ Amount of time the children are with each parent
(physical custody/visitation schedule)
❑ Who should be named as “domiciliary parent”
❑ Conditions of physical custody or visitation
(restrictions, supervision)
What type of physical custody/visitation for the other parent is now in the children’s best interest in your
opinion?
Is shared (about equal) physical custody a feasible arrangement? ❑ Yes ❑ No
Why or why not?
If you seek sole custody, briefly state the reasons (please note that joint custody is presumed to be in the best
interest of the children, and the party seeking sole custody has the burden of rebutting the presumption in
favor of joint custody by clear and convincing evidence):
Page ___ of ___
If you have asked, in pleadings already filed with the court, that the other parent’s physical
custody/visitation privileges should be supervised or should have special conditions or restrictions, please
explain the factual basis for the request.
Do you claim that the other parent has physically or sexually abused you or the children? ❑ Yes ❑ No
If the answer is yes, has a judge or the Department of Children and Family Services found abuse before?
❑ Yes ❑ No
If so, give details and attach judgment.
Has a mental health, custody or substance abuse evaluation been requested in pleadings filed with the court?
❑ Yes ❑ No
If the answer is yes, list facts which support the request.
Are you willing to participate in mediation? ❑ Yes ❑ No
(If physical abuse is an issue parties are not required to mediate.)
What is your usual and customary work schedule, holiday and vacation schedule?
What is the usual and customary work schedule, holiday and vacation schedule of the other parent?
Page ___ of ___
B. CUSTODY OR VISITATION BY A NON-PARENT
1. INFORMATION ON NON-PARENT
WHAT IS YOUR RELATIONSHIP TO THE CHILDREN? Please check below:
❑ Maternal Grandparent ❑ Other Relative _____________________ (Please specify)
❑ Paternal Grandparent ❑ Other ________________________
OTHER CASES INVOLVING THE CHILDREN (including
Support Enforcement and Protective Orders)
Docket
Number
JDC/Parish/City
Court
HAVE THE CHILDREN BEEN ADOPTED? ❑ Yes ❑ No By Whom?
2. INFORMATION ON PARENTS
Who are the parents of the children?
Were the parents married at the time of the children’s birth? ❑ Yes ❑ No
If the answer to the last question is no, did the father execute an Act of Acknowledgement? ❑ Yes ❑ No
Is father listed on the birth certificate? ❑ Yes ❑ No
Is there a Judgment of Paternity? ❑ Yes ❑ No
Please give details:
Is paternity in dispute? ❑ Yes ❑ No
Are the parent(s) of the children no longer
living? ❑ Yes ❑ No
If so, indicate which parent.
MOTHER
FATHER
Are the parent(s) of the children in jail?
❑ Yes ❑ No
If so, indicate which parent.
MOTHER
FATHER
3. VISITATION
Please answer this section if you are seeking visitation only.
DESCRIBE THE LENGTH AND QUALITY OF YOUR RELATIONSHIP WITH THE CHILDREN.
Are the children in need of guidance, enlightenment or tutelage which can best be provided by you (La. C.C.
Art. 136)? ❑ Yes ❑ No
If so, state why.
Have the children expressed a preference on your request for visitation? ❑ Yes ❑ No
Are you willing to encourage a close relationship between the children and their parents? ❑ Yes ❑ No
Are you in good physical and mental health? ❑ Yes ❑ No
Do you have special needs?
❑
Yes
❑
No
Page ___ of ___
Are the children in good physical and mental health? ❑ Yes ❑ No
Do the children have special needs? ❑ Yes ❑ No
Describe why you think it is in the children’s best interest for you to have visitation:
What visitation schedule do you propose?
Are you in contact with the children’s custodial parent? ❑ Yes ❑ No
Describe your relationship.
4. CUSTODY
Please answer this section if you seek custody
What type of custody do you seek (Sole or Joint Custody)?
Would substantial harm occur to the children if custody is not granted to you? ❑ Yes ❑ No
If the answer is yes, please provide details.
Why would a transfer of custody to you be in the children’s best interest?
Have the children been living with you in a wholesome and stable environment? ❑ Yes ❑ No
If the answer is yes, for how long?
If the children do not currently live with you, can you provide an adequate and stable home for the children?
❑ Yes ❑ No
What is your usual and customary work schedule?
Page ___ of ___
C. RELOCATION OF A CHILD’S RESIDENCE MORE THAN 75 MILES OR OUT OF STATE
1. INFORMATION ON PARENTS
What is your relationship to the children?
Who is the children’s other parent?
Were you married to the other parent at the time of the children’s birth?
❑
Yes
❑
No
If the answer to the previous question is no, and you are the father, have you signed an Act of
Acknowledgement? ❑ Yes ❑ No
Are you listed on the birth certificate? ❑ Yes ❑ No
Is there a Judgment of Paternity? ❑ Yes ❑ No
Please give details:
Is paternity contested?
❑
Yes
❑
No
OTHER CASES BETWEEN THE SAME PARTIES (including
Support Enforcement and Protective Orders)
Docket
Number
JDC/Parish/City
Court
NAMES OF YOUR OTHER CHILDREN IN
THIS CASE THAT YOU ARE SEEKING TO
RELOCATE
GENDER
CURRENT
AGE
DATE OF BIRTH
NAMES OF YOUR OTHER CHILDREN NOT
AT ISSUE IN THIS CASE
GENDER
CURRENT
AGE
DATE OF BIRTH
What type of custody do you have with these children?
Who is the primary domiciliary parent?
What is your physical custody/visitation schedule with these children?
Do you have any restrictions or conditions on your physical custody or visitation?
❑
Yes
❑
No
If so, please list and attach copy of the judgment.
Page ___ of ___
2. COURT ORDERS IN EFFECT
Is there a previous court order or judgment awarding legal custody (sole or joint)?
❑
Yes
❑
No
If the answer is yes, answer these questions:
Give details of the previous judgment on physical custody/visitation, including the date of the last judgment,
the name of primary domiciliary parent, if any, and any restrictions on physical custody or visitation.
Does the previous judgment/order have any provision about relocation?
❑
Yes
❑
No
If the answer is yes, please give details.
Is there a protective order or domestic abuse order in effect?
❑
Yes
❑
No
If the answer is yes, please give details and attach order.
3. PARENT SEEKING TO RELOCATE CHILDREN
The following questions are to be filled out only if you are the party seeking to relocate.
Where do you currently live? (City, Parish, and State)
For how long?
What is your marital status?
Who resides (besides the children at issue) in the home with you?
Do you seek to relocate with the children outside of the State of Louisiana?
❑
Yes
❑
No
If the answer is yes, where and when?
Give details of your reasons for relocation.
Page ___ of ___
Is there a court order awarding custody?
❑
Yes
❑
No
If the answer is yes, do you seek to relocate more than 75 miles from the domicile of the primary custodian at
the time the custody decree was rendered? ❑ Yes ❑ No
If the answer is no, do you seek to relocate with the children more than 75 miles from the other parent?
❑
Yes
❑
No
Have you already relocated with the children?
❑
Yes
❑
No
If the answer is yes, give details of the temporary order allowing relocation or written consent of the other
parent.
Have you requested a hearing on temporary relocation?
❑
Yes
❑
No
What notice of proposed relocation was given to the other parent?
Give the date and details. Attach a copy of the notice.
Why is relocation in the children’s best interest?
4. PARENT OPPOSING RELOCATION OF CHILDREN
The following questions are to be filled out only if you oppose relocation of the children
Where do you currently live? (City, Parish, and State)
For how long?
What is your current marital status?
Who (besides the children at issue) resides in the household with you?
Are you employed?
❑
Yes
❑
No
If the answer is yes, give details of your position and work schedule.
Did you receive notice of the proposed relocation of your children?
❑
Yes
❑
No
If the answer is yes, give the date and details.
Page ___ of ___
Why do you oppose the relocation?
Do you currently pay child support pursuant to a court order?
❑
Yes
❑
No
If the answer is yes, give the date and details.
Are you current in child support payments?
❑
Yes
❑
No
Have you ever been in arrears in payment? ❑ Yes ❑ No
Give details, including contempt proceedings and judgments.
What is your level of involvement at the current time with your children?
Do you exercise physical custody/visitation as court-ordered?
❑
Yes
❑
No
If the answer is no, give details.
Do you currently have any protective orders or domestic abuse orders in effect against you?
❑
Yes
❑
No
Page ___ of ___
II. CHILD SUPPORT AND/OR SPOUSAL SUPPORT
YOUR CURRENT EMPLOYMENT
Your Current Employer:
Address, City, State, Zip:
Telephone Number:
Position:
Length of Employment:
Gross Salary/Wages per month: $
Net Salary/Wages per month: $
Other (bonuses, commissions, interest, dividends, rental, royalties, crop income, oil & gas revenue, stock
options or shares, second jobs, etc.):
Your usual and customary work schedule:
1. Are any of the following supplied to you by
your employer?
YES
NO
VALUE (if actual value unknown,
provide estimate)
Housing
❑
❑
$
Automobile
❑
❑
$
Fuel, Mileage, or Credit Card
❑
❑
$
Meal Allowance
❑
❑
$
Travel Allowance
❑
❑
$
Health and/or Life Insurance
❑
❑
$
Other (Health club, etc.)
❑
❑
$
SELF EMPLOYED
Is your employment managed, controlled, or owned by you, a relative, or family member? ❑ Yes ❑ No
If yes, give details:
Have you provided the documents required for self-employed persons on the HOC Order?
❑
Yes
❑
No
UNEMPLOYED
Are you unemployed?
❑
Yes
❑
No
If so, indicate the last date on which you were employed:
What is the reason for the termination of your employment (quit, fired, laid-off, business closed, disabled,
etc.)?
If you are receiving unemployment, amount per week: $
Anticipated Duration:
If you are receiving social security, worker’s compensation, maintenance and cure, longshoremen and harbor
workers, or any type disability benefits, amount per month: $
Type (SSI, SSD, worker’s comp, etc.):
Anticipated Duration:
If you claim you are disabled, but are not receiving disability benefits (SSD, Workmen’s comp, Maintenance
and Cure, etc.), you must bring certified copies of your medical records with you to the hearing.
Page ___ of ___
YOUR PRIOR EMPLOYMENT
Your Prior Employer:
Address, City, State, Zip:
Telephone Number:
Position:
Length of Employment:
Wages: $
Other (bonuses, commissions, interest, dividends, rental, royalties, crop income, oil & gas revenue, stock
options or shares, second jobs, etc.):
Was the employment managed, controlled, or owned by you, a relative, or family member? ❑ Yes ❑ No
If yes, give details:
OTHER INCOME OR ASSETS
If you have any income or asset which is not shown anywhere else in this form (such as bonuses,
commissions, interest, dividends, rental, royalties, crop income, oil & gas revenue, trust income, recurring
monetary gifts or donations, second jobs, etc.), please list and explain fully:
YOUR OWNERSHIP OR INTEREST IN A HOME OR REAL ESTATE
Do you own a home and/or are you paying for a
home?
❑
Yes
❑
No
Address, City, State:
Estimated Market Value:$
Remaining Mortgage Balance: $
Monthly Payment:$
If you are not buying a home, give the name, address, and telephone number of the owner of the place where
you live:
Amount of rent (if any) or other arrangement:
Do you own or have an interest in any other real estate? ❑ Yes ❑ No
If yes, state the nature of the property and its market value, and any rental income and expenses:
YOUR CURRENT MARRIAGE/SPOUSE (if support is an issue before the court)
If you are currently married, name of your current spouse:
Your spouse’s current employer:
Address, City, State:
Telephone Number:
Page ___ of ___
OTHER PERSON’S EMPLOYMENT
1. Is the person seeking support currently employed?
❑
Yes
❑
No
2. If so, where?
3. Has the person seeking support been employed during the marriage? ❑ Yes ❑ No
If so, how long?
4. If not, why not?
5. What is the date of last employment of the person seeking support?
6. State the last income of the person seeking support: Monthly Gross: $ Monthly Net: $
Please provide as much information as you can regarding the other party’s employment, usual and customary
work hours, travel obligations, income, and benefits:
IF EITHER PARTY IS PAYING EXTRAORDINARY COMMUNITY DEBTS
Name of Debtor
Amount paid per month
Present balance of the debt
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Page ___ of ___
A. CHILD SUPPORT
1. Is this an initial child support rule or a request to modify a previous child support order?
❑
Yes
❑
No
2. If this is a modification, what is the date of the last judgment?
2a. Was child support determined as per Louisiana Support Guidelines?
❑
Yes
❑
No
3. What do you allege in your pleadings is the material change in circumstance that has occurred since the
last judgment was entered?
4. If a modification is requested, is it for an increase or a decrease in support?
5. If your request for a modification is based upon a change in your income or financial circumstances,
indicate your gross income at the time the support was last set by the court (and provide a W-2 form or other
supporting documentation), and the current amount of support ordered by the court:
6. If there are minor children in this case under five (5) years of age, please indicate the parent with whom the
children primarily reside:
7. What is the
annual
cost of childcare (be sure to include before-school, after-school, holiday, and summer
costs in your annual cost)?
Have you applied for childcare assistance? ❑ Yes ❑ No
How much will childcare assistance pay?
8. Is health insurance for the children available through the employment of either parent(s) or stepparent(s)?
❑ Yes ❑ No
9. Who currently provides health insurance for the children?
10. What is the actual cost of health insurance for only the children – you must provide documentation from
your employer or the insurance company to show the difference in cost for employee only coverage, and
employee plus children coverage, if the children are covered under a family plan.
11. If there are any children-related medical or dental expenses which are “extraordinary” (allergies, braces,
ADHD, etc.) and which require either ongoing monthly payments and/or occasional payments in excess of
$100, or any child-related extracurricular activities, please describe the nature and cost of same:
12. Are there children in private or parochial school whose support is at issue?
❑
Yes
❑
No
13. If the children’s enrollment in private or parochial school is disputed, please explain your position:
14. What is the annual cost of tuition and fees for children (registration, total annual tuition, books, supply
fees, and other mandatory fees): Please itemize separately.
Page ___ of ___
14a. Do you get or expect to get tuition assistance?
How much?
15. Have you filed a Rule seeking the right to claim the children as a tax exemption?
❑
Yes
❑
No
16. If you seek a deviation from the Louisiana Children Support Guidelines, state the reason(s) supporting
the deviation:
17. Expense Sharing – Are you sharing expenses with a third party? ❑ Yes ❑ No
If so, state the nature and amount of your expenses which are being shared with or paid by a third party.
18. Do the children receive income? ❑ Yes ❑ No
If the answer is yes, is the income of the children due to the disability of a child or a parent?
If due to disability of a parent, whose disability gave rise to the children’s income?
Who currently gets the disability check?
If the children’s income is not related to disability, please provide the nature, source and amount of the
income and documentation of same.
19. Are you paying court-ordered child support for other children? ❑ Yes ❑ No
If yes, for each list:
Parish where issued
Date of Judgment
Amount of Award
You are required to provide a certified copy of any judgment/court order or other document which
requires you to pay child support for other children.
You are required to complete Section VIII – Income and Expense Sheet
Page ___ of ___
B. SPOUSAL SUPPORT
1. If “final periodic spousal support” is opposed by you, please state the basis for opposing the claim for this
form of spousal support (lack of need, inability to pay, fault), with an explanation:
2. If you request a modification or termination of court-ordered spousal support, please state the facts
supporting your request.
3. If your request for a modification (either increase or decrease) is based upon a change in your income or
financial circumstances, state your gross and net income at the time the support was last set by the court
(provide supporting documentation):
You are required to complete Section VIII – Income and Expense Sheet
Page ___ of ___
III. USE OF FAMILY HOME/COMMUNITY MOVABLES
1. Who currently lives in the former marital home?
2. Does this party seek the continued and exclusive use of the home? ❑ Yes ❑ No
3. Does the non-resident party also seek the exclusive use of the home? ❑ Yes ❑ No
4. Who owns the former marital home?
5. Briefly state the reasons in support of your request to live in the home? (if applicable):
6. Are you requesting the exclusive use of any community or separate vehicles? ❑ Yes ❑ No
7. Who has possession of the community vehicles(s) at issue at this time?
8. List which vehicle (year, make, and model) and state whether it is community or separate property.
9. Briefly state the reasons in support of your request to have exclusive use of the vehicle (if applicable):
10. Are you requesting law enforcement assistance in returning to the home to retrieve clothing or other
necessary items? ❑ Yes ❑ No
11. Are you requesting the use and possession of any other assets (furniture, appliances, etc.)? ❑ Yes ❑ No
12. If the answer is yes, please list and provide an explanation:
13. Is rental reimbursement for the family home an issue? ❑ Yes ❑ No
If so, what is the rental value?
Please provide proof.
Page ___ of ___
IV. INJUNCTIONS
COMMUNITY
1. Has either party requested an injunction to preserve the community? ❑ Yes ❑ No
2. If there is a need for an exception to such an injunction (for example, to permit a business to be able to
continue to operate), provide a detailed explanation of the facts supporting the exception:
ABUSE / HARASSMENT
1. Has either party requested an injunction to protect a party or children? ❑ Yes ❑ No
2. If yes, provide
specific facts
which support such an injunction.
3. Are Protective Orders in effect?
❑
Yes
❑
No
4. If yes, please provide a copy of the petition and order.
Page ___ of ___
V. CONTEMPT OF COURT – CHILD OR SPOUSAL SUPPORT MATTERS
CONTEMPT
1. List each alleged count of contempt separately. For each, state the exact provision of a judgment or order
that defendant has allegedly violated. Give the date of the judgment or order.
2. Please provide the dollar value of the claim: Child Support: $___________________; Spousal Support
$___________________; Other Money Judgment $_______________________.
a. What proof does payor have that they have paid toward their ongoing monthly obligation or arrears?
b. What proof does payee have that they have not been paid on the ongoing monthly obligation or
arrears?
c. What notice was payee sent of their share of court-ordered obligations?
d. Has payor been held in contempt of court before? ❑ Yes ❑ No
e. If the answer to “d” is yes, list the date of each judgment of contempt.
f. If the answer to “d” is yes, list the violation which led to each finding of contempt and sentence
imposed by the court.
g. Please state if a “purge” has been previously set by the court, and whether it was paid. (A “purge” is an
order that gives a party more time to pay.)
3. Are you asking that the party violating the court order be sentenced to jail time? ❑ Yes ❑ No
4. Estimate the amount of attorney fees which you have incurred in seeking the relief before the court (you
should only respond to this question if you are seeking to enforce a court order
and attorney’s fees are a
remedy provided by law): $__________________
5. If the issue is reimbursement for medicals, extracurriculars, etc., list how and when demand for
reimbursement was made. Provide a summary of all such expenses and the amount of the other party’s pro-
rata share of same, and attach all supporting proof with the documents organized in the order and manner in
which the expenses are listed in the summary.
6. What is the payor’s ability to pay?
7. Is there a non-support case pending?
❑
Yes
❑ No
If the answer is yes, please provide details.
8. If you are the payor, please state any defense you may have to non-payment of the amounts claimed.
NOTICE TO PAYORS: Please be advised that your ability to pay will be an issue before the court and
you must come prepared to present testimony and evidence you want the court or hearing officer to
consider on your hearing date.
You are also required to complete the attached Section VIII – Income and Expense Sheet.
Page ___ of ___
SUPPORT PAYMENT HISTORY (Complete this section only if support arrearages are an issue before the court,
and attach additional sheets if necessary.)
Date
(mm/dd/yyyy)
Amount
Owed
Amount Paid
Arrearage or
Overpayment
Cumulative
Arrearage
or Overpayment
Notes
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
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$
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$
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$
$
$
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$
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$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
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$
$
$
$
$
$
$
$
$
$
***If additional pages are needed here, please make multiple copies of this form.
Page ___ of ___
VI. CONTEMPT OF COURT – ALL MATTERS EXCEPT SUPPORT
1. List each count of contempt separately and for each, specify the judgment or order that defendant has
allegedly violated, and specify the particular provision violated. Give date of the judgment or order, and date
of each occurrence.
2. When did the alleged acts of contempt occur?
3. What relief are you seeking?
4. Are you asking that the party violating the court order be given jail time?
❑
Yes
❑
No
5. Estimate the amount of your attorney fees directly related to your contempt claim (you should only respond
to this question if you are seeking to enforce a court order) $__________________________
Page ___ of ___
VII. MOTION TO COMPEL DISCOVERY
ANSWER TO INTERROGATORIES AND/OR REQUEST FOR PRODUCTION OF DOCUMENTS
1. Were copies of the interrogatories and the alleged insufficient responses filed with your Motion To
Compel?
❑
Yes
❑
No
2. Was a Rule 10.1 Certificate of Conference filed with your Motion To Compel?
❑
Yes
❑
No
3. Was reasonable notice of intent to file the Motion To Compel given to opposing party?
❑
Yes
❑
No
By what method?
4. Provide a list of exactly what you say was not provided, or what was deficient, and provide a copy of your
letter to the other party itemizing same, and any response thereto.
5. List reasonable expenses incurred in seeking and obtaining this order to compel (attorney fees and costs).
Page ___ of ___
VIII. INCOME AND EXPENSE SHEET
(ALL categories are to be calculated on a monthly basis; supporting documentation required.)
PARTY
CHILDREN
TOTAL
A.
GROSS MONTHLY INCOME OF PARTY
1. Wages and Commissions (Gross)
2. Bonuses (Gross)
3. Car Allowance
4. Other Expense Reimbursement
5. Interest
6. Dividends
7. Rents and Royalties (Net)
8. Business Profits (Pre-Tax)
9. Recurring Capital Gains
10. Trust Income
11. Recurring Gifts
12. Other gross monthly income of party
TOTAL GROSS MONTHLY INCOME
B.
ITEMIZED PAYROLL DEDUCTIONS
1. Federal Taxes
2. State Taxes
3. Social Security
4. Medicare
5. 401K Contributions
6. 401K Loan
7. Mandatory Retirement Contributions
8. Health Insurance
9. Life Insurance
10. Other Deductions (detail)
TOTAL MONTHLY PAYROLL DEDUCTIONS
C.
TAX LIABILITY (not deducted from payroll)
1. Federal Income Taxes
2. State Income Tax
3. Self Employment Tax
4. Other
TOTAL MONTHLY TAX LIABILITY (not deducted from
payroll)
TOTAL NET MONTHLY INCOME
D.
INCOME OF CHILDREN
1. Social Security
2. Investment
3. Trust
4. Other income of children
E.
MONTHLY EXPENSES (List current, ongoing expenses):
1. HOUSING
***See Section E(17) to add other expenses not listed hereunder.
a. Mortgage/rent
b. Second Mortgage
c. Real Estate Taxes (not included in mortgage note)
d. Homeowner’s/Condo Association Dues
e. Homeowners/Renter’s Insurance
f. Flood Insurance
Page ___ of ___
PARTY
CHILDREN
TOTAL
g. Security System
h. Furniture rental
i. Lawn care
j. Pool Service
k. Repairs/Maintenance
l. Pest Control
m. Maid service
n. Other (detail)
2. FOOD AND HOUSEHOLD SUPPLIES
3. CLOTHING
4. TRANSPORTATION/AUTOMOBILE
a. Car note/lease
b. Maintenance
c. Gas and Oil
d. Repairs
e. Insurance
5. MEDICAL AND DENTAL
a. Insurance (Hospitalization and Major Medical)
b. Insurance (Deduction from payroll, if not listed in Section B)
c. Prescriptions
d. Over the counter medications
e. Expenses not covered by insurance
f. Routine medical exams
g. Contacts/Glasses
h. Counseling
i. Dental maintenance
j. Orthodontics
6. UTILITIES
a. Water
b. Electric
c. Garbage
d. Pool
e. Cable/Satellite TV
f. Natural Gas/Propane
g. Household Phone
h. Computer
i. Cellular Phone
7. LAUNDRY AND CLEANING
8. PERSONAL AND GROOMING (Cosmetics, haircuts, nails, etc.)
9. EDUCATION EXPENSES
a. Tuition (less amount of tuition assistance)
b. Registration and Mandatory Fees
c. Transportation
d. Fees (Gym, band, cheerleading, sports, etc.)
e. Books and Supplies
f. Tutoring
g. Other (field trips, etc.)
10. CHILD CARE EXPENSES – WORK RELATED
(*Child care expenses from above are subject to reduction for
Federal Child Care Tax Credit and will be addressed by the court.)
a. School Year Daycare (less child care assistance)
b. Summer Daycare (less child care assistance)
c. Before/After Care (not included above)
d. Babysitter
11. CHILD CARE EXPENSES – NON-WORK RELATED
a. Daycare
b. Babysitter
12. GARNISHMENTS
Page ___ of ___
PARTY
CHILDREN
TOTAL
13.
JUDGMENTS OF CHILD SUPPORT (for children
other than those of this marriage/relationship
14. FIXED OBLIGATIONS
a. Credit cards (minimum monthly payment)
Account Total Balance
1. $
2. $
3. $
4. $
5. $
b. Credit union (minimum monthly payment) $
c. Department store balances
Account Total Balance
1. $
2. $
3. $
d. Life Insurance
e. Disability Insurance
f. Other insurance (detail)
15. ENTERTAINMENT/HOLIDAY EXPENSES
a. Birthdays
b. Holiday expenses
c. Gifts from children to others
d. Books, magazines, etc., subscriptions
e. Entertainment
f. Meals away from home
g. Other (detail)
16. EXTRACURRICULAR ACTIVITIES
a. Health Club Membership
b. Music Lessons/Fees
c. Dance Lessons/Fees
d. Sports Fee
e. Summer Camp
f. Equipment and Uniforms
g. Other (detail)
17. OTHER
a. Charitable contribution
b. Professional dues
c. Vacations with children
d. Pet expenses
1. Food
2. Vet/Grooming
3. Boarding
e.
f.
g.
TOTAL MONTHLY EXPENSES
Attachments: Please indicate which sections of this Income and Expense Sheet have supporting
documentation attached:
❑ A. Gross Monthly Income of Party
❑ B. Itemized Payroll Deductions
❑ C. Tax Liability (not deducted from payroll)
❑ D. Income of Children
❑ E. Monthly Expenses
Page ___ of ___
If any of the above expenses are temporary, please explain fully any anticipated changes:
__________________________________________________________________________________________
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__________________________________________________________________________________________
CERTIFICATION
STATE OF ___________________________________
PARISH OF __________________________
BEFORE ME, the undersigned notary public, personally appeared
____________________________________________________
Who, after being duly sworn, stated:
I CERTIFY that the information in this affidavit is true and correct to the best of my knowledge, information
and belief, that I will immediately correct any errors which I discover after this affidavit has been completed
and will notify (the hearing officer or court, whichever is applicable) and the other party immediately after
discovery of the error.
I CERTIFY that I will send copy of this affidavit to the other party (and the hearing officer or court, whichever
is applicable) not less than ______ days before the (the hearing officer conference or court hearing date,
whichever is applicable).
I CERTIFY that in all child custody and visitation cases, I shall have a continuing duty to advise this court of
any lawsuit concerning the children in this state or any other state which may affect the outcome of this lawsuit
(La. R.S. 13:1821) and that if I knowingly make a false statement herein that the punishment may include fines
or jail time.
I CERTIFY that I know that it is a crime to intentionally give a false answer, under oath, to any of the
questions herein (La. R.S. 14:123) and false or incomplete answers may result in fines or jail time.
I CERTIFY that I have attached copies of all financial documentation as ordered by the court.
____________________________________________
SIGNATURE OF PARTY
Sworn to and subscribed before me this _______ day of _________________, 20_______.
__________________________________________
NOTARY PUBLIC
Print name: _________________________
Bar Roll #:__________________________
My commission expires: _______________
Revised July 1, 2017
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APPENDIX 23.0B (Louisiana Supreme Court)

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Completed 18 July 2020

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