STATE OF MINNESOTA DISTRICT COURT COUNTY OF DAKOTA FIRST JUDICIAL DISTRICT File # ____________________ _________________________ Petitioner VS. AFFIDAVIT OF DEFAULT OF SUPPORT JUDGMENT, AMOUNT DUE, AND IDENTIFICATION __________________________ Respondent ________________________________, being duly sworn on oath deposes and states that he/she is the petitioner/respondent (circle one). The full name of the judgment debtor/obligor is:______________________________________. The obligor’s last known employer is ______________________________________________. The obligor’s last known address is: _________________________________, in the City of _____________________, State of _________________. The obligor’s last known post office address is ___________________________________. The obligor is not in the Armed Services. According to the court order dated _________________, the obligor is to pay $__________per _________, as and for child support. Judgment was obtained by operation of law for unpaid child support as follows: Amount Paid Amount Unpaid Payment Due Date (s) __________________ ___________ ______________ __________________ ___________ ______________ __________________ ___________ ______________ __________________ ___________ ______________ __________________ ___________ ______________ __________________ ___________ ______________ __________________ ___________ ______________ __________________ ___________ ______________ Total Amount Unpaid: $_______________________ _____________________________ (Signature) Subscribed and sworn before me on this ____________day of________, 20__ _________________________________ Notary Public American LegalNet, Inc. www.FormsWorkflow.com