State of Alabama 
Unified Judicial System 

Form CS-41 

Rev. 7/2019

CHILD-SUPPORT-OBLIGATION
INCOME STATEMENT/AFFIDAVIT 

Case Number 

IN THE ____________________________ COURT OF __________________COUNTY, ALABAMA 

 (Circuit or District)                                                               (Name of County) 

Plaintiff _____________________________ v. 

 Defendant _________________________________ 

I, ____________________________________________,  being duly sworn upon my oath, state as follows : 

(Name of Affiant) 

AFFIDAVIT 

1. I am the

 Plaintiff 

Defendant 

Other (please specify):_________________ in the above matter. 

My Social Security number is: XXX-XX-X _______  LAST THREE (3) DIGITS ONLY 

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-related

child-care:

5. The child(ren) of the parties is/are

 $______________________________ 

 (if none, write “None”) 

not covered by health-care coverage from me and/or my employer.      Health-care coverage is available at a cost 
of $______ per month.
covered by Medicaid or other public health-care coverage at no cost to me.
covered by health-care coverage, and (1) I pay $_______ each month, or that amount is paid on my behalf each

month by my________, for the family policy coverage under which the child(ren) is/are covered; and (2) the total 
number of persons covered  under that policy is ________________.    

The pro rata portion of the health-care coverage cost attributable to the child or children who are the subject 

of the support order (which shall be calculated by dividing the total health-care coverage cost  actually paid by, or 
on behalf of, the parent ordered to provide the coverage by the total number of persons (adult and/or children) 
covered and then multiplying the result by the number of children who are the subject of the support order) is the 
sum of $_______________ . 

The  health-care-coverage  company's  name  and  address  are:  _________________________________________ 
__________________________________________________________________________________________. 

6.

I pay the following total amount for
case(s) as follows:
[List case number(s) and county(ies) and state(s) here]: 
 __________________________________________    

child support  alimony in [a] prior 

 __________________________________________ 

 $______________________________ 

 (if none, write “None”) 

 I understand that I will be required to maintain all income documentation used in preparing this Income Statement/Affidavit (including 
my most recent income-tax return) and that such documentation shall be made available as directed by the court. I also understand 
that  any  intentional  falsification  of  the  information  presented  in  this  Income  Statement/Affidavit  may  subject  me  to  the  penalties  of 
perjury.  

 ______________________________________________ 

Sworn to and subscribed before me this ______ 

day of _______________________, ________ 
______________________________________ 
Notary/Clerk

 Affiant 

Form CS-41 (Back)  Rev. 7/2019

EXAMPLES OF INCOME THAT MUST BE INCLUDED IN YOUR GROSS MONTHLY INCOME 

1. Employment Income – shall include, but not be limited to, salary, wages, bonuses, commissions, severance
pay,  worker’s  compensation,  pension  income,  unemployment  insurance,  disability  insurance,  and  Social
Security benefits.

2. Self–Employment Income – shall include, but not be limited to, income from self-employment, rent, royalties,
proprietorship of a business, or joint ownership of a partnership or closely held corporation. “Gross income”
means gross receipts minus ordinary and necessary expenses required to produce this income.

3. Other Employment–Related Income – shall include, but not be limited to, the average monthly value of any
expense reimbursements or in-kind payments received in the course of employment that are significant and
reduce  personal  living  expenses,  such  as  a  furnished  automobile,  a  clothing  allowance,  and  a  housing
allowance.

4. Other Non-Employment-Related Income – shall include, but not be limited to, dividends, interest, annuities,

capital gains, gifts, prizes, and preexisting periodic alimony.

RULE 32, ALABAMA RULES OF JUDICIAL ADMINISTRATION, PROVIDES THE FOLLOWING DEFINITIONS: 

Income.  For  purposes  of  the  guidelines  specified  in  this  Rule,  “income” means  the  actual  gross  income  of  a 
parent, if  the  parent  is  employed  to  full  capacity,  or  if  the  parent  is  unemployed  or  underemployed,  then  it 
means the actual gross income the parent has the ability to earn. 

Gross Income. 

  “Gross  income” includes income from any source, and includes, but is not  limited to, income from salaries, 
wages,  commissions,  bonuses,  dividends,  severance  pay,  pensions,  interest,  trust  income,  annuities,  capital 
gains,  Social  Security  benefits,  Veteran's benefits,  workers’  compensation  benefits,  unemployment-insurance 
benefits,  disability-insurance benefits, gifts, prizes, and preexisting periodic alimony. 

  “Gross   income”  does  not  include  child  support  received  for  other  children  or benefits  received from means-
tested public-assistance  programs,  including,  but  not  limited  to,  Temporary  Assistance  for  Needy  Families , 
Supplemental Security Income, food stamps, and general assistance. 

Self–employment Income. 

  For
 income  from  self-employment,  rent,  royalties,  proprietorship  of  business,  or  joint  ownership  of  a 
partnership  or  closely  held  corporation,  “gross  income”  means  gross  receipts  minus  ordinary  and  necessary 
expenses required  to  produce  such  income,  as  allowed  by  the  Internal  Revenue  Service,  with  the  exceptions 
noted in Rule 32 (B)(3)(b). 

  Under
 those   exceptions,  “ordinary  and  necessary  expenses”  does  not  include  amounts  allowable  by  the 
Internal Revenue  Service  for  the  accelerated  component  of  depreciation  expenses,  investment  tax  credits,  or 
any other  business  expenses  determined  by  the  court  to  be  inappropriate  for  determining  gross  income  for 
purposes of calculating child support. 

    Other Income.  Expense  reimbursements  or  in-kind  payments  received  by  a  parent  in  the  course  of 
employment of self-employment or operation of a business shall be counted as income if they are significant and 
reduce personal living expenses.