FORMS FOR WITHHOLDING OF INCOME FOR CHILD SUPPORT CHAPTER 1240-2-2 (Rule 1240-2-2-.11, continued) STATE OF TENNESSEE STATE OF TENNESSEE COUNTY OF __________________ AFFIDAVIT OF ARREARAGE First being duly sworn, affiant would state: I am _____________________________, . I do hereby swear or affirm that to the best of my knowledge, information and belief, as of ___________ , the Respondent, _________________________________, is in arrears for support in the total amount of $ ______________________, which was calculated as follows: Month ___________________Year _______________ Amount $____________________ Month ___________________Year _______________ Amount $____________________ Month ___________________Year _______________ Amount $____________________ Month ___________________Year _______________ Amount $____________________ Month ___________________Year _______________ Amount $____________________ Month ___________________Year _______________ Amount $____________________ Month ___________________Year _______________ Amount $____________________ Month ___________________Year _______________ Amount $____________________ Month ___________________Year _______________ Amount $____________________ Month ___________________Year _______________ Amount $____________________ Month ___________________Year _______________ Amount $____________________ Month ___________________Year _______________ Amount $____________________ __________________________________________ Name-Please Print __________________________________________ Signature __________________________________________ Date Further affiant sayeth not. Sworn to and subscribed before me this __________ day of _________________, ______. _______________________________________ Notary Public/Court Clerk My commission expires:_________________ Authority: T.C.A. §§4-5-202, 36-5-501, 71-1-132(c), 42 United States Code §§651 et seq., 42 USC §§652(a)(11), 654(9)(E), 654a(g)(1)(A)(ii) and 666(a)(8) and (b), 45 C.F.R. §§303.6(c)(1), 303.7, and 303.100. Administrative History: Original rule filed October 14, 1999; effective December 28, 1999. October, 2005 (Revised) 1 American LegalNet, Inc. www.USCourtForms.com