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MONTANA CHILD SUPPORT GUIDELINES FINANCIAL AFFIDAVIT (State of Montana)

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MONTANA CHILD SUPPORT GUIDELINES
FINANCIAL AFFIDAVIT
INSTRUCTIONS FOR COMPLETING THIS FORM: Provide complete information, attaching additional pages if needed.
If a question or statement does not apply to you, DO NOT LEAVE IT BLANK; instead, mark it as "Not Applicable" or "N/A."
Be sure to sign this form and have your signature notarized.
A. PERSONAL INFORMATION
Full Name:
Home Address:
Mailing Address:
Work Phone No.:
Home/Cell No.:
Date of Birth:
Case Number:
Driver's License No.:
What is your tax filing status? Single Married, joint Married, separate Head of Household
List the people you claim as tax exemptions
If you are married and file taxes jointly, please provide your current spouse's annual income so that tax credits may be
calculated accurately. $
Did you finish high school?
Yes No If no, indicate highest grade completed:
List all schools attended following high school. Include training school, college or university, trade school.
School Name Course of Study Completion Date Degree/Diploma
B. CHILDREN
1. List all of your natural and adopted children (do not include stepchildren)
Child's Full Name
Date of Birth
Month/Day/Year
Who does child
live with?
Are you ordered to pay support for this
child?
No Yes $ amount/month
No Yes $ amount/month
No Yes $ amount/month
No Yes $ amount/month
No Yes $ amount/month
No Yes $ amount/month
ATTACH A COPY OF ANY ORDER REQUIRING CHILD SUPPORT TO BE PAID FOR THESE CHILDREN.
CS404.6A
1 (Rev.8/10)
Reset (this will clear all form fields)
2. Complete the table below for all expenses you pay and benefits you receive on behalf of all children shown in the
previous table. Attach proof for the items listed below. Do NOT list amounts paid by other parent.
Child's First
Name
Annual
Day Care
Costs
Annual
Unreimbursed
Medical
Expenses
Annual
Dependent's
Benefits
Received*
How many
days does
child spend
with you per
year?**
Annual
Miles
Driven for
Long
Distance
Parenting
Other
Transportation
Costs for Long
Distance
Parenting***
* For example - Social Security Benefits
** The majority of a 24 hour period the children are in your control
*** Do not include lodging, food and entertainment
No Yes $ /month reimbursement
3. Do you receive reimbursement for day care expenses?
4. If any of the children listed above have ongoing medical expenses, please describe.
5. Do you have health insurance available to you through employment or other group?
No Yes
If no, skip to Section C. If yes, to have the cost included in your child support calculation, you must do one of the
following before the final order is entered:
A. Prove that you currently have insurance coverage in effect for the children; or
B. Obtain verification from the insurance carrier that you have paid a premium with the intent to enroll the children.
Name everyone who is covered by this policy:
Regardless of whether your children are covered, complete the following:
Insurance Co. Name:
Address:
Policy Number:
Certificate Number:
$ Total cost of health insurance premium per month, including your children (whether or not you
and the children are currently enrolled).
$ Adult's portion of premium.
$ Child(ren)'s portion of premium.
$ Portion of premium to be paid by you each month.
$ Portion of premium to be paid by employer or other group each month.
2
C. EMPLOYMENT
1. List your current or most recent employer(s) first and your past two employers:
Employer's Name, Address, and Telephone
Number
Dates of Employment
Average Hours
Worked and
Current or Ending
Pay
P-Permanent
T-Temporary
S-Seasonal
From
To
hours/week
pay/hour
From
To
hours/week
pay/hour
From
To
hours/week
pay/hour
2. What kinds of work do you/did you do for your employer(s)?
3. Do you belong to a union?
No Yes If yes, name of union local, address, and amount of monthly dues:
4. Are you currently a student?
No Yes If yes, provide a copy of your most recent registration statement
showing tuition, fees, etc., and a copy of your most recent financial aid award letter. Please provide your expected
date of graduation:
5. Is there any reason, such as disability, that prevents you from being able to work full-time or from being able to earn
income at the same level you have in the past?
No Yes If yes, please explain and provide a
statement from your doctor or the Social Security Administration
6. Do you receive workers' compensation or occupational disease benefits?
No Yes
If no, are you currently seeking workers' compensation benefits or occupational disease benefits?
No Yes
If yes, who pays those benefits and what is your claim number:
7. Are you currently receiving unemployment benefits?
No Yes
If yes, name of state or agency paying those benefits:
8. If unemployed or employed part-time, have you made any efforts to find full-time employment?
No Yes
If no, why not?
If yes, describe your job search:
3
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D. INCOME
1. List all income which you receive or have received in the last 12 months.
Income Source Annual Amount Income Source Annual Amount
Gross Wages Public Assistance
Unemployment Veterans' Disability
Workers' Compensation Spousal Support
Social Security Benefits Contract Receipts
Retirement Rental Income
Interest/Dividend Income Fringe Benefits/Bonuses
Reimbursements
Profit (Loss) from
Self-employment
Educational Grants Other
2. Do you receive any non-cash benefits from your employer, such as
housing, groceries, meat, car or truck, utilities,
phone service? No Yes
If yes, describe the non-cash benefit you receive, how often you receive it, and the value of the benefit:
3. If you are self-employed, describe your self-employment activities:
How many hours per week do you spend engaged in self-employment activities?
Is your self-employment the primary source of your income for meeting your living expenses?
No Yes
4. Have you, in the past 12 months, received any prize, award, settlement or other one-time
cash payment?
No Yes If yes, describe the payment, including the amount and its present location and value.
5. ATTACH COPIES OF YOUR PAY STUBS FOR THE LAST THREE (3) MONTHS. ALSO ATTACH COMPLETE
COPIES OF YOUR FEDERAL INCOME TAX RETURNS, including all schedules filed and W-2 forms, for the last
three (3) years. If you do not have pay stubs or W-2 forms, provide employer's statement. If you are self-employed,
you must provide copies of your individual returns as well as the business (partnership or corporation) returns for the
last three (3) years. You may wish to black out or obscure confidential information such as social security numbers or
financial account numbers.
E. DEDUCTIONS AND EXPENSES
1. List deductions from gross wages, including costs for required uniforms or work related equipment. Attach pay stubs
and proof of expenses.
DEDUCTION AMOUNT HOW OFTEN PAID?
Federal Income Tax
State Income Tax
FICA and Medicare
Mandatory Retirement
Required Work Related Costs
4
2. Has a court ordered you to pay alimony? No Yes If yes, attach copy of order and proof of payments.
3. Do you have any extraordinary medical expenses for yourself, not reimbursed by insurance, your employer, or
another, which are necessary for you to maintain your health or your earning capacity? No Yes
If yes, list yearly expenses and attach proof:
4. Please list any necessary expense you pay for in-home nursing care to enable you to work and for whom the expense
is paid:
5. Is your contribution for retirement mandatory?
No Yes
6. List employment related expenses not shown elsewhere:
7. Has a court ordered you to make payments for restitution, damages, etc.?
No Yes If yes, provide a court
order and proof of payments.
8. Please attach a list of monthly expenses if you feel it is important to show your financial situation.
F. ANTICIPATED CHANGES / ADDITIONAL COMMENTS
1. Please list any changes you expect in your or your child(ren)'s circumstances during the next 18 months which
would affect the calculation of child support?
2. Additional Comments (a separate sheet may be attached):
VERIFICATION: You must sign this in front of a Notary Public.
STATE OF
COUNTY OF
I declare, subject to penalties for perjury and false swearing, that I have read the foregoing affidavit and that the
information contained in it and all attachments to it is true and correct to the best of my knowledge, information and belief.
Date Affiant
Signed and sworn before me, a Notary Public for this State, on the date and at the place written above.
NOTARY PUBLIC
(SEAL) Print Name:
Residing at:
My Commission Expires:
5
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MONTANA CHILD SUPPORT GUIDELINES FINANCIAL AFFIDAVIT (State of Montana)

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Completed 18 December 2021

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