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Uniform Support Affidavit Form. This is a Oregon form and can be use in Linn Local County.
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Tags: Uniform Support Affidavit, Oregon Local County, Linn
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
:
:
Plaintiff(s)
-against-
Calendar No.
JUDICIAL SUBPOENA
:
:
IN THE CIRCUIT COURT OF THE STATE OF OREGON
:
FOR THE COUNTY OF LINN
Defendant(s)
:
......................................................
In the Matter of the Dissolution of Marriage/Separation of::
)
)
)
THE PEOPLE OF THE STATE OF NEW YORK
____________________________________________,
)
Circuit Court No._________________________
Petitioner,
)
TO
)
Uniform Support Affidavit of:
)
Petitioner
AND
)
Respondent
GREETINGS:
)
(Child/Spousal Support Case)
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
____________________________________________,
)
Respondent
,
the Honorable
at the)
Court
located at
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
This form is a SWORN AFFIDAVIT (under oath) required for supportthis action on the It must the signed before a notary
or adjourned date, to testify and give evidence as a witness in determinations. part of be
public, may be made available to the other party, and may be filed in court. The form consists of this part, on pages 1 through
6, and any attachments requested on those pages. If either party seeks spousal support or any change from the uniform child
support guidelines, you must also complete the following and the attachments requested therein and submit all of them with
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
this form:
the party on whose behalf this1subpoena was issued and a maximum penalty Required. all damages sustained as a
Schedule - Monthly Expenses for Rebutting Factors - of $50 and
result of your failure to comply. documentation MUST be attached as indicated on page 2.
In addition, certain
STATE OF OREGON
Witness, Honorable )
Court in
County, ) ss.day of
County of ________________________)
, one of the Justices of the
, 20
I, _______________________, being first duly sworn under oath, depose and say that I am the_________________in
(Attorney must and belief:
the above-entitled matter and that the following are true to the best of my knowledge sign above and type name below)
Petitioner/Respondent
1.
2.
3.
4.
5.
6.
Your Age:
Date of Birth:
Residence Address:
Name of Employer &Address:
Occupation:
Length of Employment:
Children born of or adopted during this relationship:
Social Security Number: File under UTCR 2.100
Attorney(s) for
Title:
Office and P.O. Address
///
///
Page 1 of 6, UN IFO RM SUPP OR T A FFID AV IT of
Linn County 6D-Z.MiscForms: Uniform Support Affidavit 3-04.wpd (3/04)
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
Petitioner Respondent
American LegalNet, Inc.
www.USCourtForms.com
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:
Index No.
:
Name of Child -against-
:
Plaintiff(s)
Age
Calendar No.
Child living with:
JUDICIAL SUBPOENA
:
Me
Other Parent
Other
:
:
Defendant(s)
:
......................................................
7.
List all people living in your household (other than children named in item 6 above):
THE PEOPLE OF THE STATE OF NEW YORK
Name
Age
TO
Relationship to You
Monthly Income
GREETINGS:
8.
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
List your other dependents or children not at
located listed in items 6 or 7 above:
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
or adjourned date, to testify and give evidence as a witness in this action You part of the Monthly Income
on the
Name
Age
Relationship to
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
result of your failure to comply.
9.
Witness, Honorable
, one of the Justices of the
Court in
County,
day of
, 20
ENTER THE FOLLOWING INFORMATION FROM SCHEDULES INDICATED:
A. TOTAL GROSS INCOME (From page 4, item 16.D.)
:
B. TOTAL EXPENSES OF CHILDREN (From Schedule 1, item 1.) must sign above and type name below)
(Attorney :
C. TOTAL MONTHLY EXPENSES (From Schedule 1, item 6.)
:
10.
Attorney(s) for
(a) Are you or your present spouse entitled to receive court-ordered child support for any children now living with
you? YES NO
If “YES,” complete the following and ATTACH A COPY OF ALL SUCH CHILD
SUPPORT ORDERS.
Office and P.O. Address
Name of Child
Age
Relation to You
Support Amount
____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Telephone No.:
(b) Are those support payments being made? YES NO
Page 2 of 6, UN IFO RM SUPP OR T A FFID AV IT of
Linn County 6D-Z.MiscForms: Uniform Support Affidavit 3-04.wpd (3/04)
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
Petitioner Respondent
American LegalNet, Inc.
www.USCourtForms.com
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:
:
11.
Index No.
Calendar No.
:
Are you required to pay a court-ordered child support obligation for a child of yours who is not listed in item 6
JUDICIAL SUBPOENA
Plaintiff(s)
above? YES NO If “YES,” complete the following and ATTACH A COPY OF ALL CHILD SUPPORT
-against:
ORDERS.
:
Name of Child
Age
Name of Recipient
Monthly Support Amount
_____________________________________________________________________________________________________
:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Defendant(s)
:
......................................................
12.
Are you ordered to pay or entitled to receive court-ordered spousal support? YES NO If “YES,” complete the
following and ATTACH A COPY OF ALL SUCH SPOUSAL SUPPORT ORDERS.
Owed To
Paid By
Monthly Support Amount
THE PEOPLE OF THE STATE OF NEW YORK
_____________________________________________________________________________________________________
Owed Until:______________________________(Date or Event):________________________________________________
TO
Are you incurring child care costs on behalf of the children listed in item 6 above? YES NO If “YES,”
complete the following and attach documentation verifying the information provided below:
GREETINGS:
Name of
Day-care Provider
Monthly (gross amount before application
WE COMMAND YOU, that all business and excuses being laid aside, you and each subsidy)
child
and Address
cost of any tax credit or of you attend before
the Honorable
at the
Court
_____________________________________________________________________________________________________,
located at
County of
_____________________________________________________________________________________________________
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
or you receive any subsidy and give evidence as a witness in this action on the part of the
14.
Doadjourned date, to testify for such care? If so, amount $_________________per month.
13.
15.
MEDICAL AND DENTAL ELECTIONS--The child support recipient may elect to require the support payor to name
the child(ren) as the beneficiary on a health/dental insurance plan. If so elected, the child support may be adjusted by
Your failure or a portion of this subpoena is who provides the child’s(ren’s) portion of make you liable
an amount equal to all to comply withthe cost to parentpunishable as a contempt of court and will the health/dentalto
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
insurance premium. Please choose:
result of your failure to comply.
I wish to require health/dental insurance coverage by the other party and understand that a portion of the
Witness, Honorable
, one of the Justices of the
premium may be deducted from support.
Court in
County,
day of
, 20
I do not wish to require health/dental insurance coverage by the other party.
I provide health/dental insurance through my employer; see (Attorney item sign above and type name for information.
page 5,
18, of this schedule,
must
below)
ATTACHMENTS
REQUIRED
Attorney(s) for
Last four (4) payroll stubs.
OPTIONAL
Child care documentation if you want this
considered.
Most recent federal and state income tax return.
Medical/dental insurance documentation.
Office and P.O. Address
Copies of any and all relevant child/spousal support orders.
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
Page 3 of 6, UN IFO RM SUPP OR T A FFID AV IT of
Linn County 6D-Z.MiscForms: Uniform Support Affidavit 3-04.wpd (3/04)
Petitioner Respondent
American LegalNet, Inc.
www.USCourtForms.com
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
:
Index No.
Calendar No.
:
(INCOME, DEDUCTIONS AND MEDICAL/DENTAL INSURANCE)
JUDICIAL SUBPOENA
Plaintiff(s)
You must complete and submit the following attachments. Copies of recent: (1) federal and state income tax returns, (2) last
-against:
four pay stubs, and (3) if self-employed, most recent profits and loss statement.
16.
Your Monthly gross Income:
:
:
A. From Employment: If paid weekly, multiply weekly income be 4.3 to arrive at a monthly gross income and insert
below. If paid every two weeks, multiple two weeks’ income by 2.15 and insert below:
Defendant(s)
:
......................................................
Description
Monthly Amount
Gross Hourly Wage:_________________________________
Average Number of Hours Worked Per Week:____________
Gross OF THE STATE
_____________________________
THE PEOPLEMonthly Income: OF NEW YORK
Gross Monthly Tips/Commissions/Bonuses (identify):
_____________________________
TO
SUBTOTAL 16.A.
_____________________________
B. From Self-Employment: If you own an interest in partnership or in a closely held corporation, attach last year’s
GREETINGS: and/or corporation federal income tax return:
schedule K-1
WE COMMAND YOU, that all business and excuses being laid aside, you and Monthlyyou attend before
each of Amount
Description
the HonorableReceipts:
at the
Court
Gross
______________________ ,
located at
County of
_______
in roomExpense Reimbursements: of
, on the
day
, 20
, at
o'clock in _____________________________
the
noon, and at any recessed
Rental Income:
_____________________________
or adjourned date, to testify and give evidence as a witness in this action on the part of the
Royalty Income:
_____________________________
Less Ordinary/Necessary Expenses:
(____________________________)
Plus Monthly Portion of Accelerated Component of any Depreciation
Your failure toInvestment Tax Credits:
Allowance or comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
_____________________________
result of your failure to comply.
SUBTOTAL 16.B.
_____________________________
Witness, Honorable
, one of the Justices of the
C. Other Sources of Income: (Please attach verification 20 any income available to you as listed below):
Court in
County,
day of
, of
Description
Monthly Amount
Dividends:
_____________________________
(Attorney must sign above and type name below)
Interest Income:
_____________________________
Trust Income:
_____________________________
Contract Payments (less underlying debt):
_____________________________
Attorney(s) for _____________________________
Annuity Income:
Retirement Benefits-Pension/IRA/Keogh (nonsocial security):
_____________________________
Social Security Income:
_____________________________
Workers’ Compensation Benefits Per Week Multiplied by 4.3 =
_____________________per month
Unemployment Benefits Per Week Multiplied by 4.3= Office and P.O. Address
_____________________per month
Disability Income:
_____________________________
Gift or Prizes:
_____________________________
Spousal Support:
_____________________________
Telephone No.:
Expense Reimbursements and/or Per Diem Allowance
Facsimile No.: _____________________________
(not listed in item B. above):
E-Mail Address: _____________________________
ADC Benefits:
Mobile Tel. No.:
Page 4 of 6, UN IFO RM SUPP OR T A FFID AV IT of Petitioner Respondent
American LegalNet, Inc.
Linn County 6D-Z.MiscForms: Uniform Support Affidavit 3-04.wpd (3/04)
www.USCourtForms.com
COURT
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:
Index No.
Calendar No.
:
FCAS (food stamps):
_____________________________
JUDICIAL SUBPOENA
Plaintiff(s)
Other (specify): __________________________
_____________________________
-against:
SUBTOTAL 16.C.
_____________________________
:
D: Summary of Your Gross Income:
:
Description
Monthly Amount
Defendant(s)
:
Income. from . . . . . . . . . . . (item.16.A. .above) . . . . . . . . . . .
Employment . . . . . . . . . . . . .
_____________________________
............ ....
Self-Employed Income (item 16.B. above)
_____________________________
Other Income (item 16.C. above)
_____________________________
_____________________________
THE PEOPLE OF THE STATE OF NEW YORK
YOUR TOTAL MONTHLY GROSS INCOME: ENTER HERE and on
this Affidavit Page 2,
TO
line 9.A.
16.D. _____________________________
17.
Your Monthly Deductions from Gross Income:
GREETINGS:
A. Mandatory Deductions:
WE COMMAND YOU, that by you:___________
Number or exemptions claimedall business and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
located at
County Description
of
Monthly Amount
in roomState Income Taxes:
, on the
day of
, 20
, at
o'clock in _____________________________
the
noon, and at any recessed
Federal Income Taxes:
_____________________________
or adjourned date, to testify and give evidence as a witness in this action on the part of the
Social Security (FICA):
_____________________________
Workers’ Compensation Insurance Premium:
_____________________________
Your failure to comply with this subpoena is punishable
Wage Withholding, Wage Assignment or Garnishment: as a contempt of court and will make you liable to
_____________________________
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
(Paid to:____________________________________________)
result ofMedical Insurance for the Parties’ Joint Children if Additional
your failure to comply.
Premium Total Premium_____________– less cost of
Witness, Honorable
, one of the Justices of the
coverage for yourself + other dependants =
_____________________________
Court in
County,
day of
, 20
SUBTOTAL OF MANDATORY:
17.A. _____________________________
B. Optional Deductions:
Description
Retirement/Profit Sharing:
Savings Plan:
Credit Union:
Other:
(Attorney must sign above and type name below)
Monthly Amount
_____________________________
Attorney(s) for _____________________________
_____________________________
_____________________________
SUBTOTAL OF OPTIONAL: Office and 17.B.Address
P.O. _____________________________
C. Summary or Deductions:
Mandatory--from item 17.A. above: ____________________
Telephone No.:
Optional--from item 17.B. above: ______________________
Facsimile No.:
E-Mail Address:
TOTAL MONTHLY DEDUCTIONS 17.C. _____________________________
Mobile Tel. No.:
Page 5 of 6, UN IFO RM SUPP OR T A FFID AV IT of Petitioner Respondent
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www.USCourtForms.com
COURT
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:
:
18.
Index No.
Calendar No.
:
Information for Medical and Dental Insurance Coverage: (For children listed on page 1, item 6, of this Affidavit
JUDICIAL SUBPOENA
Plaintiff(s)
which is currently provided or available for the benefit of those children.):
-against:
I provide this (complete information below)
HEALTH INSURANCE
DENTAL INSURANCE
:
Other parent provides this (complete if known)
:
Name of Insurance Company:
____________________
Plan or Group Name:
____________________
:
Plan/Group.Number: . . . . . . . . . . . . . . . . . . . .Defendant(s) . . . . . . .
......... .......
. . . . . . . . .____________________
.
Individual I.D. Number:
____________________
Address for Claims Submission:
____________________
Phone Number for Information:
____________________
Amount of Annual THE STATE OF NEW YORK
____________________
THE PEOPLE OF Deductible:
Gross Monthly Premium Actually Paid by You
(exclude amounts paid by your employer):
____________________
TO
Monthly Premium to Cover Only You:
____________________
Dependent’s Portion of Monthly Premium:
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
Are there dependents other than children on page 1, item 6, of this Affidavit enrolled with plan? YES NO
GREETINGS:
If Yes, total number or other dependants:
____________________
____________________
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
located at
County of
Certificateroom
in of Document Preparation. Youof required to 20
, on the
day are
, truthfully complete this certificate regarding the document you
, at
o'clock in the
noon, and at any recessed
are filing with the court. Check all boxesgive evidence as ablanks that this action on the part of the
or adjourned date, to testify and and complete all witness in apply:
I selected this document for myself and I completed it without paid assistance.
I paid or will pay money to
for assistance in preparing this form.
Your failure to information this subpoena is punishable as a schedules are true to the best of you
I certify that my answers and this comply with on this affidavit and the attached contempt of court and will makemy liable to
theand ability. I further certify subpoena was issued for a attached documents is$50 andthe best of mysustained as a
party on whose behalf this that the information on the maximum penalty of true to all damages knowledge
knowledge
result of your _____ day of ____________________________, 20____.
and ability. Dated thisfailure to comply.
Witness, Honorable
Court in
County,
day of
, one of the Justices of the
________________________________________________
Signature
, 20
________________________________________________
Print Name
(Attorney must sign above and type name below)
Attorney(s) for
SUBSCRIBED AND SWORN TO BEFORE ME THIS______ DAY OF__________________________, 20_______.
________________________________________________
Notary Office and Oregon
Public for P.O. Address
My Commission Expires:____________________________
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
Page 6 of 6, UN IFO RM SUPP OR T A FFID AV IT of
Linn County 6D-Z.MiscForms: Uniform Support Affidavit 3-04.wpd (3/04)
Petitioner Respondent
American LegalNet, Inc.
www.USCourtForms.com
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
:
Calendar No.
SCHEDULE 1
(Monthly Expenses and Rebutting Factors)
:
JUDICIAL SUBPOENA
Plaintiff(s)
You must complete this schedule and prepare and submit the attachments requested in this schedule if either party seeks
:
spousal support or any change from -againstthe uniform child support guidelines. These are the total household expenses you must
pay each month. Utility bills should be averaged over the year. Any other annual, quarterly, or other periodic payments
:
should be converted to a monthly average. DO NOT LIST ANY EXPENSE IF IT IS DEDUCED FROM YOU WAGES.
ONLY INCLUDE DIRECT EXPENSES FOR JOINT CHILDREN IN SECTION 1.
:
1.
Direct monthly expenses for children of this relationship which you pay:
Defendant(s)
:
......................................................
AMOUNT
A. School Expenses:
_______________________
School Lunches:
_______________________
THE PEOPLE OF THE STATE OF NEW YORK
Books, Tuition:
_______________________
Activities:
_______________________
TO Other (Specify):
_______________________
B. Food (Other than school lunches):
_______________________
C. Day Care:
_______________________
D. Clothing:
_______________________
GREETINGS:
E. Medical Insurance--Premium Payments:
_______________________
F. Unreimbursed Health Costs:
_______________________
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
G. Unreimbursed Dental Costs:
_______________________
,
the Baby--Sitting (not work-related):
at the
Court
H. Honorable
_______________________
located at
County of
I. Lessons:
_______________________
in Grooming Needs: the
, on
day of
, 20
, at
o'clock in the
noon, and at
J. room
_______________________ any recessed
or adjourned date, to testify and give evidence as a witness in this action on the part of the
K. Hobbies, Recreation:
_______________________
L. Entertainment:
_______________________
M. Allowances:
_______________________
N. Transportation:
_______________________
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
Gasoline, Oil:
_______________________
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
Insurancefailure to comply.Child:
for Driving-Age
_______________________
result of your
O. Miscellaneous (Specify):_____________________________
_______________________
_____________________________________________________
Witness, Honorable
, one of the Justices of the
day
, 20
TOTALCourt in EXPENSESCounty,
DIRECT
OF CHILDREN: of
1. _______________________
(Add 1.A. thru 1.O.):
ENTER HERE and on Uniform Support Affidavit page 2. Line 9.B.
(Attorney must sign above and type name below)
Average Monthly Amount of Child’s Income:
Source
Amount
Name
_______________________________________________________
_______________________________________________________
Attorney(s) for
2.
Monthly Amount
FIXED COSTS
A. RESIDENCE:
Mortgage or Rent:
Property Taxes:
(If not included in mortgage)
Second Mortgage:
Other:
___________________
___________________ and P.O. Address
Office
___________________
___________________
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile
Page 1 of 3, Schedule 1, UNIFORM SUPPORT AFFIDAVIT of Petitioner Respondent Tel. No.:
Uniform Support Affidavit 3-04.wpd (12/03)
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:
:
____________________
:
____________________
Plaintiff(s)
____________________
:
B. UTILITIES:
Electricity:
Heat (other than electricity):
Water:
-againstGarbage:
Telephone:
Other:
Index No.
Calendar No.
JUDICIAL SUBPOENA
____________________
:
____________________
____________________
:
C. TRANSPORTATION:
Defendant(s)
:
. . . .Car. Payments: . . . . . . . . . . . . . . . . . . . . . ____________________
.. ........
..................
Gas &Oil:
____________________
Maintenance & Repairs:
____________________
Other (Specify):
____________________
THE PEOPLE OF THE STATE OF NEW YORK
D. INSURANCE:
TO Life:
____________________
Automobile:
____________________
Medical/Dental:
____________________
Residence:
____________________
GREETINGS:
E. FOOD AND HOUSEHOLD ITEMS:
____________________
WEfood expenses YOU, that all business and excuses being laid aside, you and each of you attend before
COMMAND for
(exclude
,
the Honorable
at the
Court
joint children covered in
located at
County of
Schedule 1, part 1, above)
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
or adjourned date, to testify and give evidence as a witness in this action on the part of the
F. CLOTHING:
____________________
Grooming/Personal Needs:
____________________
G. MEDICINE AND PHARMACEUTICAL--Unreimbursed medical/dental costs:
________________
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
H. COURT/DHR-ORDERED SUPPORT PAYMENTS:
________________
result of your failure to comply.
TOTAL FIXED COSTS (A-H):
Witness, Honorable
Court in
County,
3.
CONSUMER OBLIGATIONS:
2. ________________
, one of the Justices of the
day of
NAME OF CREDITORS
_________________________________
_________________________________
_________________________________
_________________________________
, 20
BALANCE DUE
MONTHLY PAYMENTS
______________
_____________________
(Attorney must sign above and type name below)
______________
_____________________
______________
_____________________
______________
_____________________
Attorney(s) for
TOTAL MONTHLY PAYMENTS ON CONSUMER OBLIGATIONS:
4.
3. _____________________
DISCRETIONARY EXPENSES:
A.
B.
C.
D.
Entertainment:
Vacations:
Gifts:
Religious Contributions:
Office and P.O. Address
____________________
____________________
____________________ No.:
Telephone
____________________ No.:
Facsimile
E-Mail Address:
Mobile Tel. No.:
Page 2 of 3, Schedule 1, UNIFORM SUPPORT AFFIDAVIT of Petitioner Respondent Co-Petitioner
Uniform Support Affidavit 3-04.wpd (12/03)
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COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
:
Calendar No.
____________________
____________________
:
JUDICIAL SUBPOENA
Plaintiff(s)
4. _____________________
:
E. Dues and Subscriptions:
F. Club Memberships & Dues:
TOTAL DISCRETIONARY EXPENSES:
-against5.
Index No.
ADDITIONAL EXPENSES:
_______________________________
_______________________________
:
____________________
____________________
:
TOTAL ADDITIONAL EXPENSES:
5. ______________________
Defendant(s)
:
......................................................
6.
TOTAL EXPENSES EXCLUDING DIRECT EXPENSES OF CHILD
(Add 2, 3, 4 and 5):
6. _______________________
ENTER HERE and on Uniform Support Affidavit, page 2, line 9C.
THE PEOPLE OF THE STATE OF NEW YORK
7.
Other factors that affect my income and expenses or that should be considered to rebut the presumptive child support
TO
Calculations (attach supporting documentation whenever possible):
GREETINGS:
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
located at
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
or adjourned date, to testify and give evidence as a witness in this action on the part of the
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
result of your failure to comply.
Witness, Honorable
Court in
County,
, one of the Justices of the
day of
, 20
(Attorney must sign above and type name below)
Attorney(s) for
Office and P.O. Address
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile
Page 3 of 3, Schedule 1, UNIFORM SUPPORT AFFIDAVIT of Petitioner Respondent Tel. No.:
Uniform Support Affidavit 3-04.wpd (12/03)
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