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Maine Affidavit and Agreement Form

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Maine Affidavit and Agreement Form
Maine Affidavit and Agreement Form
STATE OF MAINE
DISTRICT COURT
Location
Docket No.
Judgment Creditor
v. AFFIDAVIT AND AGREEMENT
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 OWING
INSTALLMENT
$
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. 06/00
Maine Affidavit and Agreement Form
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