OBLIGOR/OBLIGEE AFFIDAVIT REGARDING DIRECT PAYMENTS CASE NUMBER 05 - XXXX-XX I, _____________________________________________, the above named penalty of perjury, do hereby swear and/or affirm that I on the dates indicated: PAYMENT DATE PAYMENT AMOUNT received Obligor Obligee, under paid direct the following payments The total amount $_______________. received paid (as evidenced by copies of cancelled checks) through direct payment is Neither of the parties hereto have previously received any AFDC monies. Dated this __________ day of _________________________, 20_____. Affiant's Signature Printed Name Sworn to and subscribed before me this __________ day of _________________________, 20_____. Notary Public/Deputy Clerk LAW 422 Rev. 06/2005 American LegalNet, Inc. www.FormsWorkFlow.com