Form Csed 04-1606 - Affidavit Of Support

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AFFIDAVIT OF SUPPORT RECEIVED
State of ______________________)
CSED Case #__
)ss.
Non-custodian’s Name_
Judicial District/County
)
I,______________________, being first duly sworn, do swear under penalty for lying under oath,
that the following statement is to the best of my knowledge true and accurate:
1. I am the custodian of the minor children listed below
_________________________________
___________________________________
_________________________________
___________________________________
2. o
I am entitled to receive child support payments under an administrative/court child
support order.
OR
o
I do not have an administrative or judicial child support order.
3. I received the following amounts directly from the non-custodial parent as:
o
child support payments for the children listed in #1 above and
o
alimony payments pursuant to a court order.
YEAR_____________
YEAR_____________
YEAR_____________
YEAR_____________
Overnight Alimony
Overnight Alimony
Overnight Alimony
Overnight Alimony
Support
Support
Support
Support
Paid
Paid
Paid
Paid
Paid
Paid
Paid
Paid
JAN
JAN
JAN
JAN
FEB
FEB
FEB
FEB
MAR
MAR
MAR
MAR
APR
APR
APR
APR
MAY
MAY
MAY
MAY
JUN
JUN
JUN
JUN
JUL
JUL
JUL
JUL
AUG
AUG
AUG
AUG
SEP
SEP
SEP
SEP
OCT
OCT
OCT
OCT
NOV
NOV
NOV
NOV
DEC
DEC
DEC
DEC
TOTAL
TOTAL
TOTAL
TOTAL
________________________________________
Custodian
SUBSCRIBED AND SWORN to me this ____________day of _____________________, __________
Notary Public in and for ____________________
_______________________________________
My Commission Expires: ___________________
CSED 04-1606 ( Rev 7/99)

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