Free State of Minnesota - Minnesota

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District Court Judicial District: Court File Number: Case Type:



In Re the Marriage of:

Plaintiff / Petitioner vs / and

Affidavit in Support of Motion to Stop Accrual of Child Support Interest

Defendant / Respondent Intervenor STATE OF MINNESOTA ) COUNTY OF _____________________ ) SS
(County where Affidavit Signed)

My name is (Petitioner/Plaintiff) information: (Check all that apply)

(Respondent/Defendant)

I am the (check one) in this case and I state under oath the following



That I have made both complete and timely payments of both current support and court-ordered paybacks of my child support debt or arrearage. Attached to this Affidavit is proof that I have made these payments consecutively for the last 12 months.

That I am unable to pay support because of a significant physical or mental disability. Attached to this Affidavit is proof of my physical or mental disability. That I am a recipient of Supplemental Security Income (SSI), Title II Older American's Survivor's Disability Insurance (OASDI), other disability benefits, or public assistance based upon need. Attached to this Affidavit is proof of my recipient status. That I have been or will be incarcerated or institutionalized for at least 30 days for an offense other than nonsupport of the child(ren) involved, and am financially unable to pay support. The date I became incarcerated or institutionalized was and my anticipated release date is Dated: Sworn / affirmed before me this Signature (Sign only in presence of Notary or Court Deputy) day of ,

Notary Public / Deputy Court Administrator

CSX403 State

ENG

12/06

www.mncourts.gov/forms

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