Form Pc-003 - Child Protection Financial Affidavit 2009
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STATE OF MAINE
DISTRICT COURT
Location
Docket No.__________
IN RE:
CHILD PROTECTION
FINANCIAL AFFIDAVIT
(If more space is needed, attach additional sheets.)
CHILD(REN) WHO ARE THE SUBJECT OF THIS PROCEEDING:
Name of Child(ren):
Relationship to Applicant:
PERSONAL INFORMATION
Name_________________________________________
Date of Birth__________
Address_______________________________________
Telephone Number (
)______
SS Number Disclosure Required on separate form
Marital Status
single
married
divorced
separated
widowed
I live
alone
with spouse
with partner
with parent
with friend
homeless
INCOME:
1. EMPLOYMENT
a. Where do you work? (list employer name/address/telephone number)_______________________
______________________________________________________________________________
b. Length of time employed: __________
Full time
Part time
Seasonal
c. If not currently employed, when and where were you last employed? _______________________
______________________________________________________________________________
d. Do you anticipate being employed or having other income within the near future?
yes
no
If yes, explain_____________________________________________________________
2. ANNUAL INCOME Last year: _______________
Anticipated this year: ______________
3. MONTHLY/WEEKLY INCOME
a.
Salary and wages (gross pay)
$____________
per
b.
Unemployment
$____________
per week
c.
Social Security
$____________
per month
d.
TANF (AFDC)
$____________
per month
e.
Alimony/child support
$____________
per
f.
Other income (pension/workers’comp/interest/dividends/rental etc.)
$____________
per___________
Do you receive fringe benefits such as meal allowance or use of a car?
yes
no
If yes, describe____________________________________________________________
Do you receive any other kind of pay or compensation not included above?
yes
no
If yes, describe_______________________________________________
The following deductions come out of my pay in addition to taxes: (Give amounts)
Child support________
Debt payments________
Insurance_______ ___ Other_____
__
PC-003, Rev. 02/09
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