Financial Affidavit For Child Support

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State of Minnesota
District Court
County
Judicial District:
Court File Number:
lkjdfgjk
Select County
Case Type:
In Re the Marriage of:
Petitioner
and
Financial Affidavit
For Child Support
Respondent
Intervenor
STATE OF MINNESOTA
)
COUNTY OF
_____________________
) SS
(County where Affidavit Signed)
My name is
. I am the
(Petitioner)
(Respondent) in this case, and I state under
(check one)
oath the following information:
1. I am the parent of
joint child(ren) who are the subject of this court action.
(enter number of joint children)
2. My sources of income are:
Monthly Income Received
Amount
Monthly Income Received
Amount
Salary and Wages (before
Social Security Received (social security
deductions
$
disability, retirement, survivors’ benefit)
$
Self-Employment
Child’s Derivative Social Security or
$
Veteran’s Benefits
$
Unemployment Benefits
$
Workers’ Compensation
$
Commissions
$
Pension, Annuity Payments, Disability
$
Payments
Spousal Maintenance Received
$
Other source of income (list source below)
Military and Naval Retirement
$
$
Total monthly income
$
received:
3. Proof of my income is attached to form #CON112 (also called Form 11.2) and supports this
Financial Affidavit.
FAM102
State
ENG
Rev 8/07
Page 1 of 2

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