CSD303 State ENG Rev 8/18-Dwww.mncourts.gov/formsPage 1 of 7State of Minnesota District Court County of: Select County Judicial District: Court File Number: Case Type: Petitioner (first, middle, last)and Respondent (first, middle, last) In Re the Marriage of: Intervenor Affidavit in Support of Responsive Motion to Modify Child Support and/or Spousal Maintenance My name is. I state thefollowing information:Reasons Why The Existing Support Order Should or Should Not Be Changed:1. I request that the existing support/maintenance order not be changed because there hasnot been a change of circumstances for me or the other party since the order was issued. OR I request a change in the existing support/maintenance order because of:(check all that apply) Substantially increased or decreased gross monthly income of the party (check one) Obligee (receiving support/maintenance) Obligor (paying support/maintenance) Substantially increased or decreased needs of the (check at least one) joint children Obligee Obligor Change in receipt of public assistance for (check one) Obligee Obligor Substantial change in cost-of-living for (check one) Obligee Obligor Extraordinary medical and/or dental expenses for the children in this case A change in the availability of appropriate health care coverage or a substantial change in the cost of existing health care coverage Addition of work-related or education-related child care expenses or a substantialincrease or decrease in existing work-related or education related child care American LegalNet, Inc. www.FormsWorkFlow.com CSD303 State ENG Rev 8/18-Dwww.mncourts.gov/formsPage 2 of 7 expenses of the (check one) Obligee Obligor Receipt of social security benefits by the Obligee Obligor children Change in the residence of the children Emancipation of a child (name of child): Cohabitation of the Obligee with another adult Substantial change in the Parenting Time Adjustment for me other party2. I make the following other comments in support of my request for a change to the existing support/maintenance order: 3. (Skip this question if motion is for spousal maintenance only) I am the parent of the following joint children involved in this case (list only joint children involved in this case). Joint Child's Name Date of Birth Information From Existing Child Support/Maintenance Order: 4. a) The existing support order was issued by the court in County and is datedIn that Order, I am the (check one) Obligor (making payments) Obligee (receiving payments) b) There is is not a private agreement between the parties that precludes or limitsmodifications of maintenance as set form in the judgment and decree.5. At the time the existing order was issued I was (check all that apply): Unemployed Employed at (company or occupation) and earned per hour week month with a monthly gross income of . Other monthly gross income totaling from (list all sources, American LegalNet, Inc. www.FormsWorkFlow.com CSD303 State ENG Rev 8/18-Dwww.mncourts.gov/formsPage 3 of 7(such as unemployment compensation, workers' compensation, social security, or other source).6. At the time the existing order was issued, to the best of my knowledge, the other parent was (check one): Unemployed Employed at (company or occupation) and earnedper hour week month with a monthly gross income of and had other monthly gross income totaling from(list all sources,such as unemployment compensation, workers' compensation, social security, or other source).7. At the time the existing order was issued the joint children received monthly social security or veteran's benefits in the amount of: per month based on: my disability other parent's disability.This amount is paid to me other parent. does not applyCurrent Information About Me 8. I am currently (check all that apply): Married Separated Divorced Living with a companion Single9. I am currently: Employed Unemployed (if employed, answer the following): a. Employer: b. Address: c. Work telephone number: d. Occupation/Type of work: e. Length of Employment: f. Supervisor: g. Gross Pay:This does does not include overtime pay.h. Paid: Weekly Every other week Twice a month Monthly i. Previously employed by foryears prior to the above employment.10. I have the following additional sources of income (Enter amount, or zero): American LegalNet, Inc. www.FormsWorkFlow.com CSD303 State ENG Rev 8/18-Dwww.mncourts.gov/formsPage 4 of 7 Commissions Pension Payments Annuity Payments Workers' Compensation Military/Naval Retirement Unemployment Benefits Spousal Maintenance Received Disability Payments Self-Employment Other11. I receive (check only if it applies) MFIP Medical Assistance MinnesotaCare General Assistance SSI Child Care Assistance12. The joint children currently receive social security or veteran's benefits in the amount of per month based on: my disability other parent's disability.This is paid to me other parent. does not apply13. I am court ordered to pay monthly spousal maintenance. Yes No If yes, how much?14. I support the following non-joint children: Child's Name (or "none") Date of Birth Relationship to child Child support monthly amount Living in my home? Yes No Yes No Yes No Yes No Yes No(If ordered to pay child support for any child listed above, provide copies of court orders)15. My monthly expenses at the present time are as follows (If remarried, include total household expenses): Monthly Payment at Present Timea. House payment or Rent b. Real Estate Taxes, if not included in (a) c. Association Dues or Lot Rent (for property)d. Insurance American LegalNet, Inc. www.FormsWorkFlow.com CSD303 State ENG Rev 8/18-Dwww.mncourts.gov/formsPage 5 of 7 Homeowners, if not included in (a) Car Lifee. Utilities: (Average Monthly Amount) Gas Electricity Telephone Water and garbage Cable TV f. Food g. Clothing h. Laundry/dry cleaning i. Personal allowances and incidentals j. Magazine and newspapers k. Uninsured/unreimbursed medical expenses l. Uninsured/unreimbursed dental expenses m. Child care expenses n. Transportation expenses: Car payment License Gasoline Repair o. Recreation/Entertainment p. Children's needs (sports/school/hobbies) q. Allowancesr. Other (list) TOTAL MONTHLY EXPENSES:Charge accounts and loans (list):Name of Account/loanBalance Owed 1. 2. 3. 4. 5. 6. American LegalNet, Inc. www.FormsWorkFlow.com CSD303 State ENG Rev 8/18-Dwww.mncourts.gov/formsPage 6 of 7 7. (Attach a page if more space is needed16. The following people help me pay my current monthly expenses listed in question 15: Spouse Companion Roommate(s) Relatives No One17. The value of the property I currently own by myself or with someone else is: Home Household goods Purchase price of my home Balance owed on my home Other real estate Checking/savings Automobiles (year and make of vehicle) Recreational vehicles (year and make of vehicle) Personal property Stocks/bonds/etc.Court-ordered Parenting Time 18. Is there a court order that includes a parenting time schedule? Yes No If Yes, answer #19 - 21. If No, skip to #22Parents Health Care Coverage Information Only answer if you are asking for a change in health care coverage and/or dental coverage for the joint children. 22. About me: (check all that apply) I am court ordered to carry health insurance coverage for the joint children I now have private health care coverage available for the joint children I do not have or no longer have private health care coverage available for the jointchildren I cannot afford to pay my proportionate share of health care coverage for the jointchildren My proportionate share of health care coverage for the joint children should bechanged I am court ordered to maintain health care coverage for other non-joint children andcoverage is in place for other non-joint children. I have private health care coverage and/or dental insurance coverage in place for thefollowing people: American LegalNet, Inc. www.FormsWorkFlow.com CSD303 State ENG Rev 8/18-Dwww.mncourts.gov/formsPage 7 of 7 Cost of monthly health care coverage for self: Cost of monthly health care coverage for dependents:Cost of monthly dental insurance for self (if separate coverage from health care coverage):Cost of mo