COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : p STATE OF MAINE: SUPERIOR COURT , ss. Plaintiff(s) Docket No. -against- : Index No. Calendar No. DISTRICT COURT Location JUDICIAL SUBPOENA Docket No. : Plaintiff : :CHILD SUPPORT AFFIDAVIT Defendant Defendant(s) : ...................................................... Name Social Security No. Date of Birth (Parent filling STATE OF NEW THE PEOPLE OF THEout this Affidavit) YORK Address TO (street) (town or city) (state) (zip) Name and address of present employer: GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of 1. inGROSS INCOMEthe FROM WAGES, SALARY, AND SELF-EMPLOYMENT room , on day of , 20 , at o'clock in the noon, and at any recessed Attach copies of most recent W-2 form and pay stub. or adjourned date, to testify and give evidence as a witness in this action on the part of the A. How much did you earn last year? $ B. How much do you expect to earn this year? (1B) $ Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on GROSS INCOME 2. OTHER whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result NOT include TANF, SSI, general assistance or food stamps. Do of your failure to comply. Unemployment benefits Witness, Honorable Court in Workers' compensation day of County, Social Security Disability Pension or annuity Alimony Rental or mortgage income Bonuses Interest/Dividends Commissions/Tips Capital gains Other Expected this year $ , one of the Justices of the $ , 20 $ $ $ (Attorney must sign above and type name below) $ $ $ $ Attorney(s) for $ $ $ Total : (2) $ Office and P.O. Address 3. EMPLOYMENT FRINGE BENEFITS Total value of employment benefits you expect to receive this year that reduce your living expenses (car, housing, insurance, meals, etc.) (3) $ Telephone No.: 4. TOTAL GROSS INCOME EXPECTED THIS YEARFacsimile No.: (4) $ (Add 1B, 2, and 3) Put here and on line 3 of Child Support Worksheet E-Mail Address: Mobile Tel. No.: CV-050, Rev. 12/01 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. 5. YEARLY SUPPORT YOU PAY FOR OTHER CHILDREN : Child support you pay for children who are not involved in this case. Calendar No. Name of child To whom paid Amount (5) $ : -against- 6. WEEKLY HEALTH INSURANCE COST A. Cost of health insurance for yourself only. $ JUDICIALtotal here and on line 4b SUBPOENA Put : Plaintiff(s) of Child Support Worksheet : (6B) $ : B. Additional cost you pay for health insurance for the children in this case. Defendant(s) : Put this amount on line 9 of Child Support Worksheet ...................................................... 7. WEEKLY CHILD CARE COSTS Child care costs you pay so you can work or train to work. (7) $ Put this amount on line 10 of Child Support Worksheet THE PEOPLE OF THE STATE OF NEW YORK 8. WEEKLY EXTRAORDINARY MEDICAL EXPENSES TO Amount you actually pay for each child's permanent or recurring illness. Name of child Reason for expense Amount (8) $ Put total here and on line 11 of Child Support Worksheet GREETINGS: WE COMMAND YOU, that HOME 9. OTHER CHILDREN IN YOUR all business and excuses being laid aside, you and each of you attend before Other children living in your home who are not involved in this case and whom you are legally , the Honorable at the Court obligated located at County of to support. in room , on the day of , 20 , at o'clock in the noon, and at any recessed orName of child Date of birth give evidence as a witnessName ofaction on theof birth the adjourned date, to testify and Relationship to you in this child Date part of Relationship to you 10. OTHER FACTS to comply with this subpoena is punishable as a contempt of court and will make you liable to Your failure Other on whose behalf this subpoena was issued for a affect the amount of child support ordered. the partyfacts you think the Judge should know that maymaximum penalty of $50 and all damages sustained as a result of your failure to comply. Witness, DEBTS , one of the Justices of the 11. ASSETS AND Honorable Current Court in value of your assets: day of County, , 20 Real estate $ Vehicles(including recreational vehicles) $ Cash/Bank accts/CDs $ Stocks/bonds $ Retirement Plans/IRAs/401(k)s/pensions/annuities $ (Attorney must sign above and type name below) Other (such as a business interest or life insurance) $ Current balance of your debts: Mortgages $ Loans $ Credit Cards $ Attorney(s) for Other $ On my oath, and to the best of my knowledge and belief, this affidavit is complete and includes all of my income, assets, and debts. Date: Office and P.O. Address Signature Personally appeared affidavit, before me: Date: __________ who made oath to the foregoing Telephone No.: Facsimile No.: E-Mail Address: (Attorney) (Notary Public) (Deputy Clerk) Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com