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STATE OF MAINE

SUPERIOR COURT
Docket No.

, ss.

DISTRICT COURT
Location
Docket No.

Plaintiff
v.

CHILD SUPPORT AFFIDAVIT
M.R. Civ. P. 108(a)
Defendant

Name

Date of Birth
(Parent filling out this Affidavit)

SS Number Disclosure Required on separate form

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 ex