Free Microsoft Word - SCCA435.dot - South Carolina

STATE OF SOUTH CAROLINA COUNTY OF

SSN:

DOB:

vs.

SSN:

DOB:

) ) ) ) ) Plaintiff ) ) ) ) ) ) Defendant. ) )

IN THE FAMILY COURT JUDICIAL CIRCUIT AFFIDAVIT OF ARREARS
(Child Support Not Paid through Clerk of Court)

FILE NO.

DIRECTIONS 1. Do NOT keep a running balance, but calculate each month separately. 2. If your support order requires that the respondent pay medical and/or dental bills, you may include these on your Affidavit. Calculate these separately from your ongoing support. Attach copies of these bills, if you have them, to your Affidavit to support your claim. 3. The total DUE minus the total PAID equals the total BALANCE. 4. The "amount due and owing" in the affidavit is calculated by adding the balance columns for each year. 5. Attach a TRUE copy of any pay records that a court or other collection entity has maintained on payments made pursuant to the support order. 6. The signature of the affiant must be notarized. 7. Attach additional sheets as necessary. AFFIDAVIT , being first duly sworn, deposes and states that the following attachment, incorporated herein by reference, is a schedule of support payments and balances due her/him, as obligee, based on the order entered in the State of requiring per . That the amount of $ to and including . ) ) ) ) ) ) ) is due and owing as arrears from the period of , dated , the obligor, to make support payments in the amount of $

Sworn to and Subscribed before me this day of ,2

Notary Public for South Carolina My Commission expires SCCA 435 (4/02)


Signature of Affiant

Year:

COURT ORDERED PAYMENT OF MEDICAL AND/OR DENTAL BILLS
(C) (A) (B) Balance Amount Due Amount Paid (A) -( B) =(C) (F) (D) Amount Due (E) Amount Paid (D) - (E) = (F) Balance

Month

January February March April May June July August September October November December TOTALS

Year:

ON-GOING SUPPORT

COURT ORDERED PAYMENT OF MEDICAL AND/OR DENTAL BILLS
(D) Amount Due (E) Amount Paid (F) Balance (D) - (E) = (F)

Month January February March April May June July August September October November December TOTALS

(A) Amount Due

(B) Amount Paid

(C) Balance (A) -( B) =(C)

Page #

of an attachment containing

# of pages.

_________ (INITIALS OF AFFIANT)

SCCA 435b (4/02)