Child Support Affidavit
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1
2STATE 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)
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 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
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