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 COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : 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 COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : 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 COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : 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 American LegalNet, Inc. Linn County 6D-Z.MiscForms: Uniform Support Affidavit 3-04.wpd (3/04) www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : 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) American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : ____________________ : ____________________ 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) American LegalNet, Inc. www.USCourtForms.com 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) American LegalNet, Inc. www.USCourtForms.com