State of Minnesota County Select County
District Court Judicial District: Court File Number: Case Type:
In Re the Marriage of:
Plaintiff / Petitioner
Affidavit of
vs / and
(Fill in your name)
Defendant / Respondent STATE OF MINNESOTA COUNTY OF
(County where Affidavit signed)
) ) SS , being first duly sworn/affirmed, says that:
(Your name)
1. I am the Petitioner/Plaintiff/Respondent/Defendant (circle one) in this action: 2. I am employed by: Employer Address Work Number Length of Employment Gross Pay 3. I was previously employed by 4. I have the following additional sources of income: Source: $ per month $ per month Source: Source: $ per month 5. There has not been a sufficient cost-of-living or other increase in my income to allow for an adjustment in my child support.
Occupation Supervisor per (circle one) Monthly / Weekly / Semi-Monthly / Bi-Weekly for ________ years.
6. Copies of my tax returns and any other documentation of my income for the past three years,
,
(year) (year)
and
(year)
is provided to the other party of this action
as an attachment and provided to court administration. 7. I am submitting this affidavit in support of my motion to stop the cost-of-living adjustment. Dated: Subscribed and sworn to before me this Signature (Sign only in presence of Notary or Court Deputy) day of ,
Notary Public / Deputy Court Administrator
CSD403 State ENG Rev 6/08 www.mncourts.gov/forms Page 1 of 1