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vs. SHORT-FORM DOMESTIC RELATIONS AFFIDAVIT (To be used (Kansas Judicial Branch)

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In the District Court of ___________________ County, Kansas
_______________________
vs.
_______________________ Case No.
SHORT-FORM DOMESTIC RELATIONS AFFIDAVIT
(To be used for Paternity Actions, Child Support Actions, and
Post-Judgment Motions to Establish or Modify Child Support)
Name: ________________________________________________________________________
I am the : ☐ Parent ☐ IV-D Agency ☐Other: ____________________________
This case involves these dependents:
Child 1: _______________________________________Year of Birth: ____________________
Child 2: _______________________________________Year of Birth: ____________________
Child 3: _______________________________________Year of Birth: ____________________
Child 4: _______________________________________Year of Birth: ____________________
Child 5: _______________________________________Year of Birth: ____________________
Child 6: _______________________________________Year of Birth: ____________________
Please provide the following information about yourself:
Home #: ________________ Cell #: _________________ Other phone #: _________________
Email: ________________________________________________________________________
Current Mailing address: _________________________________________________________
A. How many children live in your household currently? _______________________________
B. How many children do you have that are not part of this court order? ___________________
C. What children reside with you in your home? ☐ none
CONTACT INFORMATION
CHILD(REN)
Child 1: ______________________Year of Birth: ____________ Relationship: _____________
Child 2: ______________________Year of Birth: ____________ Relationship: _____________
Child 3: ______________________Year of Birth: ____________ Relationship: _____________
Child 4: ______________________Year of Birth: ____________ Relationship: _____________
Child 5: ______________________Year of Birth: ____________ Relationship: _____________
Child 6: ______________________Year of Birth: ____________ Relationship: _____________
D. For which children do you pay child support?
☐ None ☐ Court Order ☐ Verbal Agreement
Child 1: ______________________Year of Birth: ____________ State of order: ____________
Child 2: ______________________Year of Birth: ____________ State of order: ____________
Child 3: ______________________Year of Birth: ____________ State of order: ____________
E. Do you have any parenting agreements for these children?
☐ None ☐ Court Order ☐ Verbal Agreement:
______________________________________________________________________________
F. Who claims the child(ren) for tax purposes?
☐_____________claims every year ☐ Alternate ☐ other arrangement ☐ Unknown
☐ No one
Check all levels of education you have completed:
☐ G.E.D. ☐ High School Diploma ☐ Associate Degree ☐ Bachelor Degree
☐ Graduate Degree/Professional License/Trade/Certification: ___________________________
I am currently:
☐ Not working ☐ Employed through an employer ☐ Have more than one job
☐ Self-Employed ☐ A stay-at-home parent ☐ Other: ______________________________
Employer Name: ________________________ Employer Address: _______________________
Employer Phone: __________________________ Employer Fax: ________________________
Type of Work: ___________________________ Position or Title: ________________________
☐ I am paid hourly; the amount is $________ per hour. I usually work ______ hours each week.
☐ I am paid salary; the amount is $________ every ☐week ☐two weeks ☐month ☐ year
EDUCATION & TRAINING
YOUR CURRENT WORK & OTHER INCOME
Please list information about any other jobs you currently have and/or information about
previous jobs:
Type of job/position: ___________________________________Wage/Salary: $ ____________
Type of job/position: ___________________________________Wage/Salary: $ ____________
☐ I pay $_________for work-related expenses such as union dues or uniform.
Explain: ______________________________________________________________________
☐ I have $ _________ income from other sources (side business, odd jobs, investments, etc.).
Explain: ______________________________________________________________________
I receive $ __________ ☐ Unemployment Compensation ☐ Workers Compensation
☐ Social Security Disability Insurance (SSDI) ☐ Supplemental Security Income (SSI)
☐ VA Disability ☐ Other Disability ☐ Other: _____________________________________
☐ I receive $ __________ each month Social Security benefits for a child on this case.
The other parent currently:
☐ Is not working ☐ Is employed through an employer ☐ Has more than one job
☐ Self-Employed ☐ A stay-at-home parent ☐ Other: ______________________________
Employer Name: ________________________ Employer Address: _______________________
Employer Phone: __________________________ Employer Fax: ________________________
Type of Work: ___________________________ Position or Title: ________________________
☐ The other parent is paid hourly; the amount is $________ per hour. The other parent usually
works ______ hours each week.
☐ The other parent is paid salary; the amount is $______ every ☐week ☐two weeks ☐month
☐year
Please list information about any other jobs the other parent has and/or information about
previous jobs:
Type of job/position: ___________________________________Wage/Salary: $ ____________
Type of job/position: ___________________________________Wage/Salary: $ ____________
☐ The other parent pays $_________for work-related expenses such as union dues or uniform.
Explain: ______________________________________________________________________
OTHER PARENTS’ CURRENT WORK & OTHER INCOME
☐ The other parent has $ _________ income from other sources (side business, odd jobs,
investments, etc.).
Explain: ______________________________________________________________________
The other parent receives $ __________ ☐ Unemployment Compensation
☐ Workers Compensation ☐ Social Security Disability Insurance (SSDI)
☐ Supplemental Security Income (SSI) ☐ VA Disability ☐ Other Disability
☐ Other: _____________________________________
☐ The other parent receives $ __________ each month Social Security benefits for a child on
this case.
Have you had a job in the past? ☐ Yes ☐ No
If yes, when did you become unemployed? Month: __________ Year: __________
If yes, why did you become unemployed? ☐ I was laid off ☐ I was terminated ☐ I quit
Are you looking for work? ☐ Yes ☐ No and I do not plan to
☐ Not currently, but I plan to in the future
Please list information about your last 2 jobs (if applicable):
Type of job/position: ___________________________________Wage/Salary: $ ____________
Type of job/position: ___________________________________Wage/Salary: $ ____________
Do you have trouble gaining/keeping employment or are you looking for work? Explain:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Do you pay for child care for the child(ren) on this case? ☐ Yes ☐ No
For which child(ren)? ___________________________________________________________
Does DCF pay any portion of the child care? ☐ Yes ☐ No If yes, how much? $_________
Remember: Provide documentation for each type of employment and income.
IF YOU ARE NOT CURRENTLY WORKING
If it applies, attach any proof of lay off or medical records affecting your ability to work
CHILDCARE AND HEALTH INSURANCE
Do you pay child care: ☐every month ☐ summer only ☐ after school only ☐ other: _______
How much do you pay for child care? $ _______ ☐ each week ☐ every two weeks ☐monthly
Remember: Attach receipts, a bill, a letter from a provider on business letterhead, or a notarized
letter from a provider.
Who pays for the child(ren)’s health insurance?
☐ I carry the children’s health insurance ☐ Medicaid ☐The children have no insurance
☐ My current spouse carries the children’s health insurance
☐ The other party on this case carries the children’s insurance
☐ Someone else carries the children’s health insurance
If you or your current spouse carry private health insurance for the children, we need your
current plan info:
Insurance company name: ________________________________________________________
Insurance company address: ______________________________________________________
What type of plan is it? ☐ Employee only (Single) $ __________
☐ Employee + children $ __________ ☐ Family $ _________ ☐ Other: _______________
Plan effective date: _______________ Policy #: ___________________ Group #: ___________
List all dependents covered on the plan: 1)____________________ 2) ____________________
3) _______________________ 4) ______________________ 5) ________________________
I am requesting that my child support worksheet include the following adjustments:
☐ parenting time adjustment ☐ agreement past majority
☐ income tax consideration ☐ long distance parenting time
☐ special needs ☐ overall financial conditions
other: ________________________________________________________________________
I declare under penalty of perjury under the laws of the State of Kansas that the foregoing is true,
correct and complete.
Signature: _________________________________ Date:___________________________
ADJUSTMENTS
SIGNATURE
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vs. SHORT-FORM DOMESTIC RELATIONS AFFIDAVIT (To be used (Kansas Judicial Branch)

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Completed 20 March 2021

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