Defendants Affidavit In Connection With Request For A Child Support Order {FA-12}

PLAINTIFFS NAME DEFENDANTS AFFIDAVIT IN CONNECTION WITH REQUEST FOR A CHILD SUPPORT ORDER DOCKET NO. (FOR COURT USE ONLY) TRIAL COURT OF MASSACHUSETTS COURT DIVISION DEFENDANTS NAME I, _______________________________, do state or affirm that the following is true to the best of my knowledge and belief: 1. I am the mother/father (circle one) of the following minor child(ren): ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ 2. The Plaintiff is the legal custodian of the above named child(ren). 3. I work as a ________________________________________________________________________________. I work for __________________________________________________________________________________, whose address is ____________________________________________________________________________. Gross income (income before taxes) I make $__________ per week/month (circle one). $__________ per week/month (circle one). $__________ per week/month (circle one). $__________ per week/month (circle one). 4. My gross income and my expenses are as follows: Health insurance Dental and/or vision insurance My child care expenses for child(ren) listed in Par. 1 Other child support obligations I pay I pay I pay I pay $__________ per week/month (circle one). I state that the above is true, signed under penalties of perjury. DEFENDANTS PRINTED NAME DEFENDANTS SIGNATURE FA-12 (1/12) DATE American LegalNet, Inc. www.FormsWorkFlow.com