State of Minnesota County □ District Court Judicial District: Court File Number: Case Type: In Re the Marriage of: Petitioner Financial Affidavit for Child Support and Respondent Intervenor STATE OF MINNESOTA COUNTY OF _____________________ (County where Affidavit Signed) ) ) SS ) My name is . I am the (check one)  (Petitioner)  (Respondent) in this case, and I state the following information: 1. I am the parent of joint child(ren) who are the subject of this court action. (Enter number of joint children) 2. My sources of income are: Monthly Income Received Amount Salary and Wages (before deductions $ Self-Employment $ Unemployment Benefits $ Commissions $ Spousal Maintenance Received Military and Naval Retirement Total monthly income received: $ Monthly Income Received Social Security Received (social security disability, retirement, survivors’ benefit) Child’s Derivative Social Security or Veteran’s Benefits Amount Workers’ Compensation $ Pension, Annuity Payments, Disability Payments Other source of income (list source below) $ $ $ $ $ $ 3. Proof of my income is attached to Form 11.2 and supports this Financial Affidavit. FAM102 State ENG Rev 7/15 www.mncourts.gov/forms Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 4. Number of nonjoint children who live in my home: 5. Spousal Maintenance I am court ordered to pay: A copy of the court order is attached as proof. 6. Child support I am court ordered to pay for nonjoint children and who do not live in my home: A copy of the court order is attached as proof. $ per month $ per month 7. Health care coverage information (check one or more that apply) □ I have health care coverage for the joint child(ren) in place. This □ does □ does not include dental coverage. The cost of monthly health care coverage for myself: $ per month The cost of monthly health care coverage for the joint child(ren): $ per month □ I have health care coverage for the joint child(ren) available. This □ does □ does not include dental coverage. The cost of monthly health care coverage for myself: $ per month The cost of monthly health care coverage for the joint child(ren): $ per month □ To my knowledge, the joint child(ren) receive(s) medical assistance / Minnesota Care. 8. Child care information (check one) □ There are child care expenses for the joint child(ren) in the amount of $ per month. □ There are no monthly child care expenses for the joint child(ren). □ I am unaware of any monthly child care expenses for the joint child(ren). 9. There is a court order for parenting time with the joint child(ren) (check yes or no) □ yes □ no I declare under penalty of perjury that everything I have stated in this document is true and correct. Minn. Stat. § 358.116. Dated: Signature Print Name: Address: City/State/Zip: Telephone: ( E-mail address: FAM102 State ENG Rev 7/15 www.mncourts.gov/forms ) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com