Fill and Sign the Pc 003child Protection Financial Affidavit Rev 0209 Form

STATE OF MAINE DISTRICT COURT Location Docket No.__________ IN RE: CHILD PROTECTION FINANCIAL AFFIDAVIT (If more space is needed, attach additional sheets.) CHILD(REN) WHO ARE THE SUBJECT OF THIS PROCEEDING: Name of Child(ren): Relationship to Applicant: PERSONAL INFORMATION Name_________________________________________ Date of Birth__________ Address_______________________________________ Telephone Number ( )______ Marital Status single married divorced separated widowed I live alone with spouse with partner with parent with friend homeless INCOME: 1. EMPLOYMENT a. Where do you work? (list employer name/address/telephone number)_______________________ ______________________________________________________________________________ b. Length of time employed: __________ Full time Part time Seasonal c. If not currently employed, when and where were you last employed? _______________________ ______________________________________________________________________________ d. Do you anticipate being employed or having other income within the near future? yes no If yes, explain_____________________________________________________________ 2. ANNUAL INCOME Last year: _______________ Anticipated this year: ______________ 3. MONTHLY/WEEKLY INCOME a. Salary and wages (gross pay) $____________ per b. Unemployment $____________ per week c. Social Security $____________ per month d. TANF (AFDC) $____________ per month e. Alimony/child support $____________ per f. Other income (pension/workers’comp/interest/dividends/rental etc.) $____________ per___________ Do you receive fringe benefits such as meal allowance or use of a car? yes no If yes, describe____________________________________________________________ Do you receive any other kind of pay or compensation not included above? yes no If yes, describe_______________________________________________ The following deductions come out of my pay in addition to taxes: (Give amounts) Child support________ Debt payments________ Insurance_______ ___ Other_____ __ PC-003, Rev. 02/09 SS Number Disclosure Required on separate form 4. Do you expect to receive any payments such as retroactive government benefits, tax refunds, settlements, etc? yes no If yes, describe____________________________________________ 5. Does anyone owe you money? yes no If yes, describe ASSETS AND DEBTS 1. Assets (Give current values) Real estate Car/truck Boat/rec. vehicles Bank accounts Pension Securities Any other item worth over $50______________________________________________________ 2. Debts Mortgage balance___________________ Monthly payment_____________ Loan balances_____________________ Monthly payments______________ Credit card debts___________________ Monthly payments_______________ DEPENDENTS Children (give names and dates of birth)_______________________________________________ ______________________________________________________________________ The children live with me other parent other some with me/some with others I pay support of : __________ per___________ for ________________________ Total child support paid last year__________ ; this year to date ______________ Do you have other dependents? If so, list:_______________________________________________ Does anyone provide you with support? (Spouse/partner/parent, etc.) yes no If yes, identify: ___ ______________________________________________________________________________ CHILD RELATED COSTS Cost of health insurance for children ______________ (To determine this amount, deduct the cost of insurance for yourself from the cost for the family.) Weekly child care costs so you can work or train to work____________________ Do any of your children have regular recurring medical expenses? (for example, asthma medication) yes no If yes, give details and amount _______________________________________ ______________________________________________________________________________ OTHER Describe any other facts you believe are important to understand your financial situation. ______________________________________________________________________ ______________________________________________________________________ ON MY OATH, AND TO THE BEST OF MY KNOWLEDGE AND BELIEF, THIS AFFIDAVIT IS TRUE AND INCLUDES ALL OF MY INCOME, ASSETS AND DEBTS. Date: ________________________ Signature Subscribed and sworn to before me: Date: ________________________ (Attorney)(Notary)(Deputy Clerk) Based on review of the parent’s financial circumstances, including an interview with the parent, I make the following recommendation: Eligible Not eligible Partially eligible $ RECOMMENDATION: Date: Screener: