Free Microsoft Word - CSX1103 - Minnesota

State of Minnesota County Select County

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



In Re the Marriage of:

Plaintiff / Petitioner

Affidavit of
vs / and

(Fill in your name)
Defendant / Respondent Intervenor STATE OF MINNESOTA COUNTY OF
(County where Affidavit signed)

) ) SS

, being first duly sworn/affirmed, says that:
(Your name)

1. I am the Petitioner/Plaintiff/Respondent/Defendant (circle one) in this action: 2. I am employed by: Employer Address Work Number Length of Employment Gross Pay

Occupation Supervisor per (circle one) Month / Week / Semi-Monthly / Bi-Weekly for ________ years.

3. I was previously employed by 4. I have the following additional sources of income: Source: $ per month Source: $ per month Source: $ per month

5. There has not been a sufficient cost-of-living or other increase in my income to allow for an adjustment in my child support. 6. Copies of my tax returns and any other documentation of my income for the past three years, , and is provided to the other party of this action
(year) (year) (year)

and the county attorney as an attachment and provided to the Court Administrator. 7. I am submitting this affidavit in support of my motion to stop the cost-of-living adjustment. Dated: Signature (Sign only in presence of Notary or Court Deputy) Subscribed and sworn to before me this day of , Notary Public / Deputy Court Administrator
CSX1103 State ENG Rev 6/08 www.mncourts.gov/forms Page 1 of 1