Financial Disclosure Affidavit Form (Page 7 of 8) in pdf

Attachment 4

Step 9: AFFIRMATION

The foregoing statements and a rider consisting of ____ page(s) annexed hereto and made a part thereof, have

been carefully read by the undersigned. I affirm that the foregoing is true and correct and represents all income,

benefits, and assets held by me or due and owing to me, as well as all expenses, liabilities, loans and debts incurred by

me. At the time of signing this Affidavit I have no knowledge of any additional source(s) of income, benefits, and

assets to which I am entitled. I understand that the Support Collection Unit (SCU) is relying upon the information

that I am providing herein in its determination as to whether I am eligible for an agreement for a modification of my

support order and/or a compromise of support arrears pursuant to this pilot program.

I understand that failure to disclose, in full, information that is pertinent to the questions above could result in

denial of my request for modification of my support order and/or arrears compromise. I further understand that if I

present the SCU with false or misleading information, or a misrepresented claim, which is used as the basis for an

Agreement to Modify Order of Support and/or Compromise Arrears (Agreement), and the Agreement is then accepted

by the court and a modified order of support is issued based on such information, the SCU may bring a motion to

vacate and nullify such order. In such instance, the SCU has the right to request permission from the court to re-apply

all amounts affected by the compromise to my account, reinstate previously existing judgments of arrears, disregard

the modified order, and enforce the prior order. I understand that if the modified order is vacated by the court, the

SCU will take any action or institute any and all proceedings which might have been taken if the Agreement had not

been entered into.

I solemnly affirm under the penalty of perjury that the above information is true to the best of my knowledge,

information and belief.

_________________________________

____________________

Signature of Noncustodial Parent

Date

Sworn to before me this __________

Day of_________________ , 20___

_____________________________

Notary Public

Financial Disclosure Affidavit Form Page 7