Affidavit of Financial Information · Step 4 of 6

Children

Name Write the full name of your first child shared with the other party. Date of Birth Write the day, month, and year this child was born. Name Write the full name of your second child shared with the other party. Date of Birth Write the day, month, and year this child was born. Name Write the full name of your third child shared with the other party. Date of Birth Write the day, month, and year this child was born. Name Write the full name of your fourth child shared with the other party. Date of Birth Write the day, month, and year this child was born. Name Write the full name of another person you help support who is not your child in this case. Age Write how old that person is. Relationship to You Write how this person is related to you, like parent or stepchild. Reside With You (Y/N) Write Y if this person lives with you, or N if they do not. Court Order to Support (Y/N) Write Y if a court ordered you to support this person, or N if not. Do you have health insurance available? Check Yes if you can get health insurance through your job or another plan. Check No if you cannot. Are you enrolled? Tell whether you are signed up for the health insurance right now. Total monthly cost Write the full amount you pay each month for your health insurance plan. Premium cost to insure you alone Write how much it costs each month to cover only yourself. Premium cost to insure child(ren) common to the parties Write the extra monthly cost to cover the children you and the other parent share. List all people covered by your insurance coverage: List the names of everyone who is covered by your health insurance. Name of insurance company and Policy/Group Number: Write the name of your health insurance company and your policy or group number. This helps prove your coverage. Total monthly cost Write the full amount you pay each month for dental or vision insurance. Premium cost to insure you alone Write how much it costs each month to cover only yourself. Premium cost to insure child(ren) common to the parties Write the extra monthly cost to cover the children you and the other parent share. List all people covered by your insurance coverage: List the names of everyone who is covered by your dental or vision insurance. Name of insurance company and Policy/Group Number: Write the name of your dental or vision insurance company and your policy or group number. Name(s) of child(ren) cared for and amount per child: Write the name of the first child who gets the child care. Name(s) of child(ren) cared for and amount per child: Write the name of the second child who gets the child care. Name(s) of child(ren) cared for and amount per child: Write the name of the third child who gets the child care. Name(s) and address(es) of child care provider(s): Write the name and address of each person or place that provides the child care. Name(s) and relationship of minor child(ren) who you support or who live with you, but are not common to the parties. List the names of any children under 18 who you take care of or who live with you but are not the children of both you and the other party. Include how each child is related to you.

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