Form Pc-003-Child Protection Financial Affidavit
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2STATE 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_____________
4. Do you expect to receive any payments such as retroactive government benefits, tax refunds, settlements,
etc?
yes
no If yes, describe_______________________________________________________________
PC-003, Rev. 02/09
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