Affidavit In Support Of Motion To Modify Child Support {CSX-203}

CSX203 State ENG Rev 8/18-Dwww.mncourts.gov/formsPage 1 of 7State of Minnesota District Court County ofSelect County Judicial District: Court File Number: Case Type: Petitioner (first, middle, last) and Respondent (first, middle, last) In Re the Marriage of: Intervenor Affidavit in Support of Motion to Modify Child SupportI state that the following information is true and correct to the best of my knowledge. 1. My name is. In this case, I am the Obligor (paying child support) Obligee (receiving child support)2. In this case, the child support is for: Child's Name Date of Birth Is there court-ordered parenting time? Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No(Include another page if more space is neededIf you and the other parent have any other minor children together who are not part of this court case, write the children's names and dates of birth here: American LegalNet, Inc. www.FormsWorkFlow.com CSX203 State ENG Rev 8/18-Dwww.mncourts.gov/formsPage 2 of 7Is there a support case open for any of these children? Yes No3. I ask the court to modify the current child support order. I will provide proof that there has been a substantial change in finances or other circumstances since the last court order. I request a change in the current basic support order because of: (check all that apply) Substantial change in gross income for me other party Substantial change in needs for me other party children in this case Change in receipt of public assistance for me other party Substantial change in cost-of-living for me other party New, extraordinary medical or dental expenses for the children in this case Change in receipt of social security benefits for me other party child Change in the residence of the children Emancipation of a child (name of child): Substantial change in the Parenting Time Adjustment for me other party4. I make the following other comments in support of my request for a change to the existing basic support order: (Explain the items you checked at #3. For example, why have living expenses gone up or down? Include documents or bills that help to prove what you are saying.) 5. I ask the court to change the current order for health care support for the children: Yes No If No, skip to #6.6. I ask the court to change the current order for Child Care/Day Care Obligation: Yes No If No, skip to #7.7. The existing support order was issued by the court in County and is dated.8. At the time the existing order was issued I was: Unemployed Employed at (company or occupation) with a monthly gross income offrom this employment. I had other monthly gross income totalingor none from(list all sources, such as unemployment compensation, workers' compensation, social security, or other source). American LegalNet, Inc. www.FormsWorkFlow.com CSX203 State ENG Rev 8/18-Dwww.mncourts.gov/formsPage 3 of 79. At the time the existing order was issued the other parent was: Unemployed Employed at (company or occupation) with a monthly gross income offrom this employment. The order does not include this information, or I don't know this information. The other parent had other monthly gross income totalingor None or I don't know from: (list all sources, such as unemployment compensation, workers' compensation, social security, or other source).10. At the time the existing order was issued the children listed above at #2 received social security or veteran's benefits in the amount of: None OR per month based on: my disability other parent's disability.This amount is paid to me other parent.11. I am currently (check all that apply): Married Separated Divorced Living with a companion Single12. I am currently: Employed Unemployed13. I have the following additional sources of income (Enter amount, or zero): Commissions Pension Payments Annuity Payments Workers' Compensation Military/Naval Retirement Unemployment Benefits Spousal Maintenance Received Disability Payments "RSDI" Social Security Retirement, Survivors or Disability Income (not SSI) Self-Employment Tribal or per capita income Other14. I will file proof of my income and Form 11.2 with the court and serve on the other parent. (Include pay stubs or tax return)15. I receive (check only if it applies) MFIP Medical Assistance MinnesotaCare General Assistance American LegalNet, Inc. www.FormsWorkFlow.com CSX203 State ENG Rev 8/18-Dwww.mncourts.gov/formsPage 4 of 7 SSI Child Care Assistance16. The children currently receive social security or veteran's benefits in the amount of per month based on: my disability other parent's disability.This is paid to me other parent.17. I am court ordered to pay monthly spousal maintenance. Yes No If yes, how much?18. In addition to the children at #2, I am the legal parent of another (non-joint) minor child: Yes NoYou are probably the legal parent if: You are the biological mother, and your parental rights have not been terminated You legally adopted the child You are the biological father, and your parental rights have not been terminated, and one of the following is true: you were married to the mother when the child was conceived or born you were found to be the father in a Paternity action you signed a Recognition of Parentage (ROP) or other legal document in which you and the mother acknowledged you are the father you have a court order regarding child support for the child19. My monthly expenses at the present time are as follows (If married, include total household expenses. List all your expenses, even if someone else helps pay them.): Monthly Payment at Present Timea. House payment or Rent b. Real Estate Taxes, if not included in (a) c. Association Dues or Lot Rent (for property)d. Insurance Homeowners, if not included in (a) Car Lifee. Utilities: (Average Monthly Amount) Gas Electricity Telephone Water and garbage Cable TV f. Food American LegalNet, Inc. www.FormsWorkFlow.com CSX203 State ENG Rev 8/18-Dwww.mncourts.gov/formsPage 5 of 7 g. Clothing h. Laundry/dry cleaning i. Personal allowances and incidentals j. Magazine and newspapers k. Uninsured/unreimbursed medical expenses l. Uninsured/unreimbursed dental expenses m. Child care expenses n. Transportation expenses: Bus, Train, Taxi Car payment License Gasoline Repair o. Recreation/Entertainment p. Children's needs (sports/school/hobbies) q. Allowancesr. Other (list) TOTAL MONTHLY EXPENSES: $0.00 Charge accounts and loans (list):Name of Account/loanBalance Owed 1. 2. 3. 4. 5. 6. 7. (Attach another page if more space is needed20. The following people help me pay my current monthly expenses listed in question 19: Spouse Companion Roommate(s) Relatives No One21. The value of the property I currently own by myself or with someone else is: Home Household goods Purchase price of my home Balance owed on my home American LegalNet, Inc. www.FormsWorkFlow.com CSX203 State ENG Rev 8/18-Dwww.mncourts.gov/formsPage 6 of 7 Other real estate Checking/savings Automobiles year and make of vehicle Recreational vehicles year and make of vehicle Personal property Stocks/bonds/etc.Court-Ordered Parenting Time 22. Is there a court order that includes a parenting time schedule? Yes No If Yes, answer #23 - #25. If No, skip to #26Current Information about the Other Parent 26. To the best of my knowledge, the other parent is currently: Employed Unemployed I do not know27. To the best of my knowledge, the other parent has the following additional sources of income: (enter amount, or zero) Commissions Pension Payments Annuity Payments Workers' Compensation Military/Naval Retirement Unemployment Benefits Spousal Maintenance Received Disability Payments "RSDI" Social Security Retirement, Survivors or Disability Income (not SSI) Tribal or per capita income Self-Employment Other28. To the best of my knowledge, the other parent receives: MFIP Medical Assistance MinnesotaCare General Assistance SSI Child Care Assistance29. To the best of my knowledge, the other parent is ordered to pay spousal maintenance: Yes No I do not know If yes, how much?30. To the best of my knowledge, the other parent is the legal parent of minor children from a different relationship as listed below.Child's Name (or "none")Date of BirthCourt-ordered to pa