STATE OF MAINE DISTRICT COURT Location Docket No. Judgment Creditor v. Judgment Debtor I, 1. 2. 3. 4. 5. My address is I am employed by in the capacity of My gross pay is $ per My net pay, after deductions for federal income tax, FICA, state income tax and withholding ordered by a court or state agency, is $ per Other amounts deducted from my wages by my employer are: ITEM AMOUNT , being duly sworn, depose and say: AFFIDAVIT AND AGREEMENT 14 M.R.S. § 3125(2) . . 6. TOTAL: I am under a court order to pay the following debts, which are not withheld from my wages: AMOUNT OF PERIODIC INSTALLMENT $ $ $ per per per TOTAL AMOUNT OWING $ $ $ DEBT OWED TO 7. 8. 9. I have dependents. My spouse receives income of $ My necessary living expenses are $ per per Page 1 of 2 from . MJ/SC-001, Rev. 06/14 American LegalNet, Inc. www.FormsWorkFlow.com 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. . The parties acknowledge that the balance due, as of this date, is $ Date: Signature of Debtor Personally appeared the above-named made oath that the foregoing statements are true. Date: and 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 . The judgment creditor agrees that the balance due, as of this date, is as stated above. Date: (Attorney for) Judgment Creditor MJ/SC-001, Rev. 06/14 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com