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IN THE DISTRICT COURT FOR THE 		 JUDICIAL DISTRICT
FOR THE STATE OF IDAHO, IN AND FOR THE COUNTY OF 				

						,
		Petitioner,
	vs.

						,
		Respondent.
	
Case No. 					

AFFIDAVIT VERIFYING INCOME

I hereby certify that the following information is true:	
Your Name		Other Parent’s
Name	
A. GROSS INCOME				
1.	Wages, salary, commissions, bonuses, etc.				
2. Rent, royalties, trade, or business income, etc. 
    (net of ordinary & necessary expenses)				
3. Interest, dividends, pensions, annuities, etc.				
4. Social security, worker's compensation, disability,    
    unemployment benefits, veterans' benefits, etc.				
5. Public assistance, welfare for self (not children)				
6. Alimony				
7. Grants, distributions from trusts, etc.					
8. Other					
9. SUBTOTAL				
	
Your Name		Other Parent’s
Name	
B. DEDUCTIONS FROM GROSS INCOME 				
    (I.C.S.G. Sections F and G)				
1. Straight line depreciation on assets				
2. One-half of self-employment Social Security taxes				
3. Child support & alimony from another relationship				
4. Support for child of another relationship living in the 
    home				
5. DEDUCTIONS SUBTOTAL				
C. GROSS INCOME, AS ADJUSTED
     (line B5 subtracted from line A9)				
D. IN-KIND BENEFITS (I.C.S.G. Section F(2))
    (housing, food, transportation, recreation)				
E. POTENTIAL INCOME (I.C.S.G. Section F(3))
    Potential earned income + Potential unearned income				
F. GUIDELINES INCOME (C + D + E)				
G. MONTHLY I.C.S.G. INCOME (F12 months)				

CERTIFICATION UNDER PENALTY OF PERJURY

I certify under penalty of perjury pursuant to the law of the State of Idaho that the foregoing is true and correct.

Date: 				

Typed/Printed Name	 				 	Signature