PLAINTIFFʼS AFFIDAVIT IN SUPPORT OF REQUEST FOR A CHILD SUPPORT ORDER DOCKET NO. (FOR COURT USE ONLY) PLAINTIFFʼS NAME TRIAL COURT OF MASSACHUSETTS DEFENDANTʼS NAME COURT DIVISION I, _______________________________, do state or affirm that the following is true to the best of my knowledge and belief: 1. The Defendant is the mother/father (circle one) and I am the legal custodian of the following child(ren). ____________________________________________ ____________________________________________ 2. The Defendant works as a ____________________________________________ ____________________________________________ ____________________________________________________________________. The Defendant works for ______________________________________________________________________, whose address is ____________________________________________________________________________. 3. My gross income and my expenses are as follows: Gross income (income before taxes) Health insurance Dental and/or vision insurance My child care expenses for child(ren) listed in Par. 1 Other child support obligations I make $__________ per week/month (circle one). I pay I pay I pay I pay $__________ per week/month (circle one). $__________ per week/month (circle one). $__________ per week/month (circle one). $__________ per week/month (circle one). 4. Based on my knowledge, the Defendantʼs gross income and his/her expenses are as follows: Gross income (income before taxes) S/he makes $__________ per week/month (circle one). Health insurance S/he pays Dental and/or vision insurance Defendant’s child care expenses for child(ren) listed in Par. 1 Other child support obligations S/he pays $__________ per week/month (circle one). S/he pays $__________ per week/month (circle one). S/he pays $__________ per week/month (circle one). $__________ per week/month (circle one). I state that the above is true, signed under penalties of perjury. PLAINTIFFʼS PRINTED NAME DATE PLAINTIFFʼS SIGNATURE FA-11 (1/12) American LegalNet, Inc. www.FormsWorkFlow.com