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Maine Child Support Affidavit Form

In order to settle the amount of money each parent will have to provide for a minor child after a divorce, the Maine Child Support Affidavit Form has to be completed by both spouses involved in the divorce.

 

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STATE OF MAINE 
SUPERIOR COURT            DISTRICT COURT   
 	
, ss.   Location     	 
Docket No.                                   	
   Docket No.    	 
        
      
                                                             	
Plaintiff 
 
vs. CHILD SUPPORT AFFIDAVIT 
         
                                                             
Defendant 
 
  Name                                                                     	
       Date of Birth         	 	
  (Parent filling out this Affidavit) 	 	
   
  Address                                                                                                                                                   	  	
 	(street)   (town or city)   (state)  (zip)	 	
 
Name and address of present employer:  
 
          
 
 
1.  GROSS INCOME FROM WAGES, SALARY, AND SELF-EMPLOYMENT  
  Attach copies of most recent W-2 form and pay stub. 
  A.  How much did you earn last year?    $      	
 
  B.  How much do you expect to earn this year?    (1B) $     	
  
2.  OTHER GROSS INCOME  
 Do NOT include TANF, SSI, general assistance or food stamps. 
        Expected this year 
    Unemployment benefits    $                           	
    
    Workers' compensation     $                           
      
    Social Security       $                           
      
    Disability         $                           
      
    Pension or annuity       $                           
      
    Alimony        $                           
       
    Rental or mortgage income    $                           
       
    Bonuses        $                           
       
    Interest/Dividends      $                           
       
    Commissions/Tips      $                           
       
    Capital gains        $                           
  
    Other                                            	
  $                           	       
                             Total :   (2) $     	
 
3.  EMPLOYMENT FRINGE BENEFITS  
  Total value of employment benefits you expect to receive this year  
  that reduce your living expenses  (car, housing, insurance, meals, etc.)    (3) $             
 
                                         
4.  TOTAL GROSS INCOME EXPECTED THIS YEAR       (4) $       	
  (Add 1B, 2, and 3)                    	Put here and on line 3 of Child Support Worksheet  
 
FM-050, Rev. 02/09 	
 
 	
SS Number Disclosure Required on separate form

5. YEARLY SUPPORT YOU PAY FOR OTHER CHILDREN 
  Child support you pay for children who are not  involved in this case. 
  Name of child       To whom paid        Amount            (5) $                             
                               	                                  	                               	        	Put total here and on line 4b 	
               	      	      	  	of Child Support Worksheet	  
 
6.  WEEKLY HEALTH INSURANCE COST 
  A. Cost of health insurance for yourself only.  $                          	
        
 B. Additional cost you pay for health insurance for the children     (6B) $                             	
      in this case.            	Put this amount on line 9	 of Child Support 
Worksheet	
  
 
7.  WEEKLY CHILD CARE COSTS          
  Child care costs you pay so you can work or train to work.     (7) $                             	
                               	Put this amount on line 10	 
             	
of Child Support Worksheet	   
8.  WEEKLY EXTRAORDINARY MEDICAL EXPENSES   
  Amount you actually pay for each child's permanent or recurring illness. 
  Name of child                 Reason for expense           Amount     (8) $                             	
                                    	                                     	                              	  	Put total here and on line 11	 
                                    	
                                     	                              	  	of Child Support Worksheet	 
 
9.  OTHER CHILDREN IN YOUR HOME 
  Other children living in your home who are not involved in this case and whom you are legally 
  obligated to support. 
 	
Name of child     Date of birth     Relationship to you         Name of child       Date of birth      Relationship to you 	
                        	                   	                                	             	     	       	  
                        	
                   	                                	             	     	       	  
 
10. OTHER FACTS 
  Other facts you think the Judge should know that may affect the amount of child support ordered. 
                                                                                                                                                                
  
                                                                                                                                                                
  
 
11. ASSETS AND DEBTS 
 Current value of your assets:        
  Real estate  $                         	
      Vehicles(including recreational vehicles) $   	 
  Cash/Bank accts/CDs $                      	
      Stocks/bonds  $                               	 
  Retirement Plans/IRAs/401(k)s/pensions/annuities   $                                 
 
  Other (such as a business interest or life insurance)   $                                
 
 Current balance of your debts:       
  Mortgages $                     	
 Loans $                       	 Credit Cards $                    	 Other $     	             
 
On my oath, and to the best of my knowledge and belief, this affidavit is complete and includes all of my 
income, assets, and debts. 
 
Date:                                          	
                                                                              	
               Signature 
 
Personally appeared                                                               	
__________        	 who made oath to the 
foregoing affidavit, before me: 
 
Date:                                          	
                                                                                	 
                            (Attorney) (Notary Public) (Deputy Clerk)
Next: Maine Acknowledgment and Receipt of Summons Form Previous: Maine Child Support Worksheet Form
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