State of Minnesota County Ƒ District Court Judicial District: Court File Number: Case Type: In Re the Marriage of: Plaintiff / Petitioner Affidavit of vs / and (Fill in your name) Defendant / Respondent STATE OF MINNESOTA COUNTY OF ) ) SS (County where Affidavit signed) , being first duly sworn/affirmed, says that: (Your name) 1. I am the Petitioner/Plaintiff/Respondent/Defendant (circle one) in this action: 2. I am employed by: Employer Address Work Number Length of Employment Gross Pay Occupation Supervisor per (circle one) Monthly / Weekly / Semi-Monthly / Bi-Weekly 3. I was previously employed by for ________ years. 4. I have the following additional sources of income: Source: $ per month Source: $ per month Source: $ per month 5. There has not been a sufficient cost-of-living or other increase in my income to allow for an adjustment in my child support. 6. Copies of my tax returns and any other documentation of my income for the past three years, , (year) and (year) is provided to the other party of this action (year) as an attachment and provided to court administration. 7. I am submitting this affidavit in support of my motion to stop the cost-of-living adjustment. Dated: Subscribed and sworn to before me this Signature (Sign only in presence of Notary or Court Deputy) day of , Notary Public / Deputy Court Administrator CSD403 State ENG Rev 6/08 www.mncourts.gov/forms Page 1 of 1 American LegalNet, Inc. www.FormsWorkflow.com