CSX403 State ENG Rev 7/15www.mncourts.gov/formsPage 1 of 1State of Minnesota District Court County of:Select County Judicial District: Court File Number: Case Type: In Re the Marriage of: Petitioner (first, middle, last) and Respondent (first, middle, last) Intervenor Affidavit in Support of Motion to Stop Accrual of Child Support Interest My name is , I am the (check one) Petitioner Respondent in this case and I state the following information:(check all that apply That I have made both complete and timely payments of both current support and court-ordered paybacks of my child support debt or arrearage. Attached to this Affidavit is proof that I have made these payments consecutively for the last 12 months. That I am unable to pay support because of a significant physical or mental disability. Attached to this Affidavit is proof of my physical or mental disability. That I am a recipient of Supplemental Security Income (SSI), Title II Older American's Survivor's Disability Insurance (OASDI), other disability benefits, or public assistance based upon need. Attached to this Affidavit is proof of my recipient status. That I have been or will be incarcerated or institutionalized for at least 30 days for an offense other than nonsupport of the children involved, and am financially unable to pay support.The date I became incarcerated or institutionalized was and my anticipated release date is .I declare under penalty of perjury that everything I have stated in this document is true and correct. Minn. Stat. 247 358.116. Dated: Signature County and State where signed American LegalNet, Inc. www.FormsWorkFlow.com