Fill and Sign the Fillable Online Courts Maine Mjsc 001 Affidavit Ampamp Agreement Rev Form

STATE OF MAINE DISTRICT COURT Location Docket No. Judgment Creditor v. AFFIDAVIT AND AGREEMENT 14 M.R.S. § 3125(2) Judgment Debtor I, , being duly sworn, depose and say: 1. My address is 2. I am employed by in the capacity of 3. My gross pay is $ per . 4. My net pay, after deductions for federal income tax, FICA, state income tax and withholding ordered by a court or state agency, is $ per . 5. Other amounts deducted from my wages by my employer are: ITEM AMOUNT TOTAL: 6. I am under a court order to pay the following debts, which are not withheld from my wages: DEBT OWED TO AMOUNT OF PERIODIC TOTAL AMOUNT INSTALLMENT OWING $ per $ $ per $ $ per $ 7. I have dependents. 8. My spouse receives income of $ per from 9. My necessary living expenses are $ per . MJ/SC-001, Rev. 06/14 Page 1 of 2 10. I agree to pay $ per commencing to . I understand that if I fail to make two or more payments, the creditor can obtain an order requiring my employer to withhold this amount from my wages. I also understand that if I fail to make the payments, I can be held in contempt of court and sentenced to jail. The parties acknowledge that the balance due, as of this date, is $ . Date: Signature of Debtor Personally appeared the above-named and made oath that the foregoing statements are true. Date: Notary Public/Attorney/Clerk AGREEMENT The judgment creditor agrees to the entry of an order requiring the debtor to make installment payments of $ per payable to commencing . The judgment creditor agrees that the balance due, as of this date, is as stated above. Date: (Attorney for) Judgment Creditor MJ/SC-001, Rev. 06/14 Page 2 of 2