Free MJ-SC-001, Affidavit and Agreement, Rev. 06/00 - Maine

STATE OF MAINE DISTRICT COURT Location Docket No. Judgment Creditor v. AFFIDAVIT AND AGREEMENT

Judgment Debtor

I, and say: 1. My address is

, being duly sworn, depose

2. I am employed by in the capacity of 3. My gross pay is $ per . 4. My net pay, after deductions for federal income tax, FICA, state income tax and withholding ordered by a court or state agency, is $ per . 5. Other amounts deducted from my wages by my employer are: ITEM AMOUNT

TOTAL: 6. I am under a court order to pay the following debts which are not withheld from my wages: DEBT OWED TO AMOUNT OF PERIODIC TOTAL AMOUNT OWING INSTALLMENT $ $ $ 7. 8. 9. I have dependents. My spouse receives income of $ My necessary living expenses are $ per per per $ $ $

per per

from .

MJ/SC-001, Rev. 06/00

10. I agree to pay $ per commencing to . I understand that if I fail to make two or more payments, the creditor can obtain an order requiring my employer to withhold this amount from my wages. I also understand that if I fail to make the payments, I can be held in contempt of court and sentenced to jail. Date: Signature of Debtor Personally appeared the above-named made oath that the foregoing statements are true. and

Date: Notary Public / Attorney / Clerk

AGREEMENT The judgment creditor agrees to the entry of an order requiring the debtor to make installment payments of $ per payable to commencing .

Date: (Attorney for) Judgment Creditor