STATE OF MAINE DISTRICT COURT Location ______________________ Docket No. ____________________ IN RE: CHILD PROTECTION FINANCIAL AFFIDAVIT (If more space is needed, attach additional sheets.) CHILD(REN) WHO ARE THE SUBJECT OF THIS PROCEEDING: Name of Child(ren): Relationship to Applicant: PERSONAL INFORMATION Name ________________________________________________ Date of Birth _______________________ Address ______________________________________________ Telephone Number ___________________ SS Number Disclosure Required on separate form Marital Status I live single alone married with spouse divorced with partner separated with parent widowed with friend homeless INCOME: 1. EMPLOYMENT a. Where do you work? (list employer name/address/telephone number) ______________________________ ______________________________________________________________________________________ b. Length of time employed: ________________________ Full time Part time Seasonal c. If not currently employed, when and where were you last employed? ______________________________ ______________________________________________________________________________________ d. Do you anticipate being employed or having other income within the near future? yes no If yes, explain __________________________________________________________________________ 2. ANNUAL INCOME Last year: ___________________ Anticipated this year: _____________________ 3. MONTHLY/WEEKLY INCOME a. Salary and wages (gross pay) $________________ per b. Unemployment $________________ per week c. Social Security $________________ per month d. TANF (AFDC) $________________ per month e. Alimony/child support $________________ per f. Other income (pension/workers' comp/interest/dividends/rental etc.) $________________ per Do you receive fringe benefits such as meal allowance or use of a car? yes no If yes, describe__________________________________________________________________________ Do you receive any other kind of pay or compensation not included above? yes no If yes, describe__________________________________________________________________________ The following deductions come out of my pay in addition to taxes: (Give amounts) Child support___________ Debt payments_____________ Insurance___________ Other_____________ 4. Do you expect to receive any payments such as retroactive government benefits, tax refunds, settlements, etc? yes no If yes, describe_______________________________________________________________ PC-003, Rev. 02/09 1 of 2 5. Does anyone owe you money? yes no If yes, describe ASSETS AND DEBTS 1. Assets (Give current values) Real estate Car/truck Boat/rec. vehicles Bank accounts Pension Securities Any other item worth over $50______________________________________________________________ 2. Debts Mortgage balance_______________________________ Monthly payment_____________________ Loan balances__________________________________ Monthly payment_____________________ Credit card debts________________________________ Monthly payment_____________________ DEPENDENTS Children (give names and dates of birth)_________________________________________________________ _________________________________________________________________________________________ The children live with me other parent other some with me/some with others I pay support of : _________________ per_______________ for ____________________________________ Total child support paid last year____________________; this year to date _____________________________ Do you have other dependents? If so, list:_______________________________________________________ Does anyone provide you with support? (Spouse/partner/parent, etc.) yes no If yes, identify: _________________________________________________________________________________________ CHILD RELATED COSTS Cost of health insurance for children ___________________________________________________________ (To determine this amount, deduct the cost of insurance for yourself from the cost for the family.) Weekly child care costs so you can work or train to work____________________________________________ Do any of your children have regular recurring medical expenses? (for example, asthma medication) yes no If yes, give details and amount _____________________________________________________ OTHER Describe any other facts you believe are important to understand your financial situation. _________________________________________________________________________________________ _________________________________________________________________________________________ ON MY OATH, AND TO THE BEST OF MY KNOWLEDGE AND BELIEF, THIS AFFIDAVIT IS TRUE AND INCLUDES ALL OF MY INCOME, ASSETS AND DEBTS. Date: Subscribed and sworn to before me: Date: _________________________________________ (Attorney)(Notary)(Deputy Clerk) _________________________________________ Signature Based on review of the parent's financial circumstances, including an interview with the parent, I make the following recommendation: Eligible Not eligible Partially eligible $ RECOMMENDATION: Date: Screener: PC-003, Rev. 02/09 2 of 2