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Alabama CS-41 Form (Front and Back)

Alabama CS-41 Form (Front and Back)

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Published by Roger Shuler
Front and back of Alabama's CS-41 form
Front and back of Alabama's CS-41 form

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Published by: Roger Shuler on Oct 06, 2011
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10/06/2011

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State of AlabamaUnified Judicial System
Form CS-41 Rev. 1/09
CHILD SUPPORT OBLIGATION
 
INCOME STATEMENT/AFFIDAVIT
 
Case Number
 
IN THE
____________________________
COURT OF __________________COUNTY, ALABAMA
(Circuit or District) (Name of County)
Plaintiff _____________________________
 
v. Defendant _________________________________
 
AFFIDAVIT
I, ____________________________________________, being duly sworn upon my oath, state as follows :
(Name of Affiant)
1. I am the Plaintiff Defendant Other (please specify):_________________ in the above matter.My Social Security number is:_____________________________________2. I am currently employed. My employer’s name and address are: _____________________________________________________________________ _____________________________________________________________________not currently employed.My last employer’s name and address are: _______________________________________ _________________________________________________________________________Last position title: __________________________________________________________Average monthly salary in the last year of employment: $ ___________________________3. My monthly gross income includes:
(
For example of income that must be included, see back of this form. If income varies by month, enter the estimated average monthly gross income.)
 
Employment income $______________________________Self-employment income $______________________________Other employment-related income $______________________________Other non-employment related income $______________________________Total $ _______________________________4. I incur the following amount monthly for work-relatedchild-care: $______________________________(
if none, write “None”)
5. The child(ren) of the parties is/arenot covered by health insurance from meand/or my employer.covered by health insurance and I pay thefollowing amount monthly for the insurance $______________________________coverage.
(if none, write “None”)
6. I pay the following total amount for child support alimony in [a] priorcase(s) as follows:[List case number(s) and county(ies) and state(s) here]: __________________________________________ $______________________________
(if none, write “None”)
 __________________________________________
I understand that I will be required to maintain all income documentation used in preparing this Income Statement/Affidavit
(includingmy most recent income tax return)
and that such documentation shall be made available as directed by the court. I also understandthat any intentional falsification of the information presented in this Income Statement/Affidavit may subject me to the penalties of perjury.
  ______________________________________________AffiantSworn to and subscribed before me this ______day of _______________________, ________ ______________________________________
Notary/Clerk
 

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