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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: