Free EXPEDITED CHILD SUPPORT PROCESS - Minnesota

State of Minnesota County

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



In Re the Marriage of:

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

Affidavit in Support of Motion to Modify Child Support and/or Spousal Maintenance

My name is . I state under oath the following information: Reasons Why the Existing Order Should Be Changed 1. I request a change in the existing order because of (check all that apply): Substantially increased or decreased gross income of the party (check one) Obligee (receiving support/maintenance) Obligor (paying support/maintenance) Substantially increased or decreased needs of the (check at least one) joint child(ren) Obligee Obligor Receipt of public assistance by the (check one) Obligee Obligor A change in the cost-of-living for (check one) Obligee Obligor Extraordinary medical and/or dental expenses of the child(ren). A change in the availability of appropriate health care coverage or a substantial change in the cost of existing health care coverage. Addition of work-related or education-related child care expenses or a substantial increase or decrease in existing work-related or education-related child care expenses of the (check one) Obligee Obligor Receipt of social security benefits by the Obligee Obligor child(ren) A change in the residence of the child(ren) Emancipation of a child (name of child): _________________________. 2. I make the following other comments in support of my request for a change to the existing support/maintenance order:

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3.

(Skip this question if motion is for spousal maintenance only) I am the parent of the following joint child(ren) involved in this case (list only joint child(ren) involved in this case). Joint Child's Name Date of birth

Information From Existing Child Support Order (Answer only those questions that apply) 4. The existing support/maintenance order was issued by the court in ________________County and is dated ___________________________. In that Order, I am the (check one) Obligor (making payments) Obligee (receiving payments) 5. At the time the existing order was issued, I was (check all that apply): Unemployed Employed at (company or occupation) and earned $ per hour week month with a monthly gross income of $ Other monthly gross income totaling $_________________ from (list all sources, such as unemployment compensation, workers' compensation, social security, or other source). At the time the existing order was issued, to the best of my knowledge, the other parent was (check one): Unemployed. (company or occupation) and Employed at earned $ per hour week month with a monthly gross income of $ and had other monthly gross income totaling $_________________ from (list all sources, such as unemployment compensation, workers' compensation, social security, or other source). At the time the existing order was issued, the joint child(ren) received monthly social based on security or veteran's benefits in the amount of $ my disability other parent's disability and is paid to me other parent

6.

7.

Current Information About Me 8. I am currently (check all that apply): Married Separated Divorced 9. I am currently (check one) employed following): a. Employer: b. Address: c. Work telephone number: d. Occupation /Type of work: e. Length of employment: f. Supervisor:
State ENG Rev-01/08

Living with a companion

Single

unemployed (if employed, answer the

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g. h. i. 10.

Gross Pay: $_________________ This does does not include overtime pay. Paid: Weekly Every other week Twice a month Monthly Previously employed by for ___________ years prior to the above employment. Pension Payments $ Unemployment Benefits $ Workers' Compensation $ Disability Payments $ Other $ MinnesotaCare

I have the following additional sources of income: Commissions $ Annuity Payments $ Military / Naval Retirement $ Spousal Maintenance Received $ Self-Employment $ I receive (check only if it applies) General Assistance SSI

11. 12.

MFIP Medical Assistance Child Care Assistance

The joint child(ren) currently receives monthly social security or veteran's benefits in the amount of $ based on my disability the other parent's disability and is paid to me other parent. I am court ordered to pay monthly spousal maintenance. (check one) YES NO If yes, how much? I support the following nonjoint child(ren): Child's Name Date of Birth Relationship

13. 14.

Child support Living in monthly amount my home $ Yes / No $ Yes / No $ Yes / No $ Yes / No $ Yes / No (If ordered to pay child support for any child listed above, provide copies of court orders) 15. My monthly expenses at the present time are as follows (if remarried, include total of household expenses): Monthly Payment at Present Time a. House payment or Rent $ b. Real Estate Taxes, if not included in (a) $ c. Association Dues or Lot Rent (for property) $ d. Insurance: Homeowners, if not included in (a) $ Car $ Life $ e. Utilities: (Average Monthly Amount) Gas $ Electricity $ Telephone $ Water and garbage $ Cable TV $
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f. g. h. i. j. k. l. m. n.

o. p. q. r. s.

Food Clothing Laundry/dry cleaning Personal allowances and incidentals Magazine and newspapers Uninsured / unreimbursed medical expenses Uninsured / unreimbursed dental expenses Child care expenses Transportation expenses: Car payment License Gasoline Repairs Recreation/Entertainment Child(ren)'s needs (sports/school/hobbies) Allowances Other (list) Charge accounts and loans (list): Name of Account 1. 2. 3. 4. 5. TOTAL MONTHLY EXPENSES:

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Balance Owed $ ____________________ $ ____________________ $ ____________________ $ ____________________ $ ____________________ $

16. 17.

The following people help me pay my current monthly expenses listed in question 15: Spouse Companion Roommate(s) Relatives No One The value of the property I currently own by myself or with someone else is: Home $____________________ Household goods $____________________ Purchase price of my home $_________________ Balanced owed on my home $____________________ Other real estate $____________________ Checking/savings $____________________ Automobiles $____________________ (year and make) Recreational vehicles $____________________ (year and make) Personal property $____________________ Stocks/bonds/etc. $____________________

Current Information About Other Parent 18. To the best of my knowledge, the other parent is currently: (check one) employed unemployed (if employed, answer the following): a. Employer: b. Address: c. Work telephone number: d. Occupation / Type of work:
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e. f. g. h. i. 19.

Length of employment: Supervisor: Gross Pay: $_________________ This does does not include overtime pay. Paid: Weekly Every other week Twice a month Monthly Unknown Previously employed by for ___________ years prior to the above employment.

To the best of my knowledge, the other parent has the following additional sources of income: Commissions $ Pension Payments $ Annuity Payments $ Unemployment Benefits $ Military / Naval Retirement $ Workers' Compensation $ Spousal Maintenance Received $ Disability Payments $ Self-Employment $ Other $ To the best of my knowledge, the other parent receives (check only if it applies) MFIP Medical Assistance MinnesotaCare General Assistance SSI Child Care Assistance To the best of my knowledge, the other parent is ordered to pay spousal maintenance. (check one) YES NO If yes, how much? To the best of my knowledge, the other parent supports the following nonjoint child(ren): Child's Name Date of Birth Relationship Child support Living in monthly amount the home $ Yes / No $ Yes / No $ Yes / No $ Yes / No $ Yes / No

20.

21. 22.

Parents Health Care Coverage Information Only answer if you are asking for a change in health care coverage and/or dental coverage for the joint child(ren). 23. About me: (check all that apply) I am court ordered to carry health care coverage for the joint child(ren) I now have private health care coverage available for the joint child(ren) I do not have or no longer have private health care coverage available for the joint child(ren) I cannot afford to pay my proportionate share of health care coverage for the joint child(ren) My proportionate share of health care coverage for the joint child(ren) should be changed I am court ordered to maintain health care coverage for other nonjoint children and coverage is in place for other nonjoint children. I have private health care coverage and/or dental insurance coverage in place for the following people: Cost of monthly health care coverage for self: $ Cost of monthly health care coverage for dependents: $
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Cost of monthly dental insurance for self (if separate coverage from health care coverage): $ Cost of monthly dental insurance for dependents (if separate coverage from health care coverage): $ 24. Currently, there is: no court order that directs either parent to carry private health care coverage for the joint child(ren). a court order that directs me the other parent to carry private health care coverage for the joint child(ren). Medical Assistance MinnesotaCare currently in place for the joint child(ren). About the other parent: (check all that apply) The other parent is court ordered to carry health care coverage for the joint child(ren) The other parent has private health care coverage available for the joint child(ren) The other parent does not have or no longer has private health care coverage available for the joint child(ren) The other parent is court ordered to maintain health care coverage for other nonjoint children and coverage is in place for other nonjoint children. The other parent has private health care coverage and/or dental insurance coverage in place for the following people: Cost of monthly health care coverage for self: $ Cost of monthly health care coverage for dependents: $ Cost of monthly dental insurance for self (if separate coverage from health care coverage): $ Cost of monthly dental insurance for dependents (if separate coverage from health care coverage): $ Child Care Obligation Only answer if you are asking for a change in child care support for the joint child(ren). 26. I am court ordered to pay a proportionate share of child care support and the amount of child care support has changed. There is no court ordered child care obligation and I have child care expenses. 26. 27. If there is an existing court order for monthly child care expenses, list the court ordered amount: $ The current total monthly costs of child care are $

25.

The information contained in this Affidavit is true and correct to the best of my knowledge.
Dated: Signature (Sign only in presence of Notary or Court Deputy) Sworn / affirmed before me this day of , Print Name: Address: City/State/Zip: Notary Public / Deputy Court Administrator Telephone: ( )

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