Petition to Modify Child Support — Property & Finances

a. General Information

The Order was issued on: Enter the date the support order was signed by the judge. Use month, day, and year. The Order was issued by: Write the name of the court that made the order you want to change. Located in this County: Write the county where that court is located. Name of Person ordered to pay: Write the full name of the person who was told to pay support in the order. Total Current Amount Ordered Paid: $ Write the total dollar amount of support that must be paid now. PER Write how often this total is paid, like each month or each week.

b. Child Support

Child Support $ Write the part of the total that is just for child support. Child Support per Write how often child support is paid, like each month or each week. Spousal Maintenance/Support $ Write the part of the total that is for spousal support, if any. Spousal Maintenance/Support per Write how often spousal support is paid, like each month or each week. Other (i.e. Clearinghouse fee): $ Write the dollar amount for any other fees, like a clearinghouse fee. Other (i.e. Clearinghouse fee): per Write how often the other fee is paid, like each month or each week. Payments in Arrears: $ Write the dollar amount for past-due payments you still owe. Payments in Arrears: per Write how often the past-due payment is made, like each month. The order I wish to change is on page Write the page number in the order where the part you want to change is found. section/paragraph Write the section or paragraph number of the part you want to change. Is the Division of Child Support Enforcement (DCSE) providing Child Support Services to at least one of the parties? Check Yes if a state child support agency is helping with your case, No if not, or Unknown if you are not sure. [ ] YES 1. I listed all sources of my income. Check Yes if you wrote down every place your money comes from. [ ] NO 1. I listed all sources of my income. Check No if you did not list all your income sources. You must explain this on a separate page. [ ] YES 2. I attached copies of my two (2) most recent pay stubs. Check Yes if you added your last two pay stubs to this form. [ ] NO 2. I attached copies of my two (2) most recent pay stubs. Check No if you did not add your two recent pay stubs. You must explain why on a separate page. [ ] YES 3. I attached copies of my federal income tax return for the last three (3) years, and I attached my W-2 and 1099 forms from all sources of income. Check Yes if you added your tax returns from the last three years plus your W-2 and 1099 forms. [ ] NO 3. I attached copies of my federal income tax return for the last three (3) years, and I attached my W-2 and 1099 forms from all sources of income. Check No if you did not add those tax papers. You must explain why on a separate page. Name Write the full name of the first person who lives in your home.

c. Children's Basic Information

Date of Birth Write the birth date of this household member. Relationship to you Write how this person is related to you, such as spouse, child, or parent. Income Write how much money this person earns each month before taxes. Name Write the full name of the second person who lives in your home. Date of Birth Write the birth date of this household member. Relationship to you Write how this person is related to you, such as spouse, child, or parent. Income Write how much money this person earns each month before taxes. H. Attorney's Fees paid in this matter $ Write the dollar amount you have paid your lawyer for this case. Source of funds Tell where the money to pay your lawyer came from, such as savings or a loan. A. Your job/occupation/profession/title: Write your job title or the kind of work you do. Name and address of current employer: Write the name and full address of the company where you work now. Date employment began: Write the date you started this job. Weekly Check this box if you get paid once every week. Every other week Check this box if you get paid once every two weeks. Monthly Check this box if you get paid once a month. Twice a month Check this box if you get paid twice a month, such as on the 1st and 15th. Other Check this box if you get paid on a different schedule than the choices listed. [ ] Other Describe how often you get paid if none of the boxes fit. B. If you are not working, why not? If you do not have a job, explain why, such as a layoff or health problem. C. Previous employer name and address: Write the name and full address of the company where you used to work. Previous job/occupation/profession/title: Write the job title or kind of work you did at your last job. Date previous job began: Write the date you started your previous job. Date previous job ended: Write the date your previous job ended. Reason you left job: Explain why you left your last job, such as quit, fired, or laid off. Gross monthly pay at previous job: $ Write the amount you earned each month at your last job before taxes were taken out. Year Write the first of the last three years from your tax returns. $ Write your total income for that year from your tax return. Year Write the second of the last three years from your tax returns. $ Write your total income for that year from your tax return. Year Write the third of the last three years from your tax returns. $ Write your total income for that year from your tax return. E. Your total gross income from January 1 of this year to the date of this Affidavit (year-to-date income): $ Write how much money you have earned before taxes since January 1 of this year up to today. A. High School: List the high school name, how long you went, the last year you attended, and any diploma you earned. B. College: List the college name, how long you went, the last year you attended, and any degree you earned. C. Post-Graduate: List any graduate school, how long you went, the last year you attended, and any degree you earned. D. Occupational Training: List any job or trade training, how long it lasted, the last year you attended, and any certificate you earned. A. Gross salary/wages per month Enter your total pay each month before any taxes or deductions are taken out. Rate of Pay $ Enter how much you are paid for the time period you will check below, such as your hourly or yearly rate. [ ] hour Check this if the rate of pay you wrote is for each hour you work. [ ] week Check this if the rate of pay you wrote is for each week you work. [ ] month Check this if the rate of pay you wrote is for each month you work. [ ] year Check this if the rate of pay you wrote is for the whole year. 1. Automobile Enter the monthly value of a car your employer pays for. Write 0 if none. 2. Auto expenses, such as gas, repairs, insurance Enter the monthly amount your employer pays for car costs like gas, repairs, or insurance. Write 0 if none. 3. Lodging Enter the monthly value of housing your employer pays for. Write 0 if none. 4. Other (Explain) Describe any other expense your employer pays for that wasn't listed above. 4. Other (Explain) $ Enter the monthly amount for the other employer-paid expense you described. C. Commissions/Bonuses Enter the monthly amount you earn from commissions or bonuses. Use a monthly average if it changes. D. Tips Enter the monthly amount you earn in tips. Use a monthly average if it changes. E. Self-employment Income (See below) Enter your monthly income from working for yourself or your own business. F. Social Security benefits Enter the monthly amount you receive from Social Security. Write 0 if none. G. Worker's compensation and/or disability income Enter the monthly amount you receive from workers' compensation or disability. Write 0 if none. H. Unemployment compensation Enter the monthly amount you receive in unemployment benefits. Write 0 if none. I. Gifts/Prizes Enter the monthly value of any gifts or prizes you receive. Write 0 if none. J. Payments from prior spouse Enter the monthly money you get from a former husband or wife, such as alimony. Leave blank if none. K. Rental income (net after expenses) Enter the monthly money you make from renting out property, after you subtract the costs of owning it. L. Contributions to household living expense by others Enter the monthly amount other people give you to help pay for your home and living costs. M. Other (Explain:) Describe any other income not already listed, like dividends, pensions, interest, or royalties. M. Other (Explain:) $ Enter the monthly dollar amount for the other income you just described. TOTAL: Add up all the income amounts above and write the total here. Name, address and telephone no. of business: Write the name, full address, and phone number of the business you own or run. Type of business entity: Enter the kind of business it is, such as sole owner, partnership, LLC, or corporation. State and Date of incorporation: If your business is a corporation, write the state where it was formed and the date it started. Nature of your interest: Explain what part you own or your role in the business, like owner, partner, or shareholder. Nature of business: Describe what the business does or sells. Percent ownership: Enter the share of the business you own as a percentage. Number of shares of stock: If the business has stock, write how many shares you own. Total issued and outstanding shares: Write the total number of stock shares the business has given out. Gross sales/revenue last 12 months: Enter the total money the business made from sales over the past 12 months, before any costs.

d. Health & Medical Support

Drugs and medical supplies Enter how much you pay each month for medicine and medical supplies after any insurance pays its share. Other Describe any other monthly medical or dental cost you pay that is not covered above. Other Enter the monthly dollar amount for the other medical or dental cost you described. TOTAL: Add up the medicine, supplies, and other amounts and write the total here. Total monthly child care costs Enter how much you pay each month for child care. Do not include money paid by D.E.S. YES Check this box if your job lets you pay child care costs with pretax money (a cafeteria plan). NO Check this box if you do not use an employer pretax plan for child care costs. Court ordered spousal maintenance/support you actually pay to previous spouse: Enter the monthly dollar amount of spousal support you actually pay to a former spouse, if a court ordered you to pay it. For Children (Educational Expense/Special Needs/Other): Enter the monthly dollar amount you spend on unusual costs for your children, like special schooling or medical needs. Explain: Describe what the children's extra expenses are for, so the court understands why you listed that amount. For Self: Enter the monthly dollar amount you spend on unusual costs for yourself, like special medical needs. Explain: Describe what your own extra expenses are for, so the court understands why you listed that amount. First Mortgage Enter how much you pay each month for your first home loan. Second Mortgage Enter how much you pay each month for a second home loan, if you have one. Homeowners Association Fee Enter your monthly homeowners association fee, if your neighborhood charges one. Rent Enter how much rent you pay each month if you rent your home. Repair & upkeep Enter what you spend each month to fix and maintain your home. Yard work/Pool/Pest Control Enter monthly costs for yard care, pool service, or pest control. Insurance & taxes not included in house payment Enter monthly home insurance and property taxes only if they are not part of your house payment. Other (Explain): Describe any other monthly housing cost not listed above. Other (Explain): Enter the monthly dollar amount for the other housing cost you described. TOTAL: Add up all your housing costs above and write the total here. Water, sewer, and garbage Enter what you pay each month for water, sewer, and trash service. Electricity Enter your monthly electric bill. Gas Enter your monthly gas bill. Telephone Enter your monthly home phone bill. Mobile phone/pager Enter your monthly cell phone or pager bill. Internet Provider Enter your monthly internet bill. Cable/Satellite television Enter your monthly cable or satellite TV bill. Other (Explain): Describe any other monthly utility cost not listed above. Other (Explain): Enter the monthly dollar amount for the other utility you described. TOTAL: Add up all your utility costs above and write the total here. Food, milk, and household supplies Enter what you spend each month on groceries and household items. School lunches Enter what you pay each month for school lunches. Meals outside home Enter what you spend each month eating out or buying meals away from home. TOTAL: Add up all your food costs above and write the total here. Clothing for you Enter how much you spend each month on your own clothes. Uniforms or special work clothes Enter your monthly cost for uniforms or special clothes you need for work. Clothing for children living with you Enter how much you spend each month on clothes for the children who live with you. Laundry and cleaning Enter your monthly cost for washing clothes, dry cleaning, and laundry supplies. TOTAL: Add up all the clothing amounts above and write the total here. Car insurance Enter how much you pay each month for car insurance. List all cars and individuals covered: List each car and the people covered by your car insurance. Car payment, if any Enter your monthly car loan or lease payment, if you have one. Car repair and maintenance Enter your average monthly cost for fixing and maintaining your car. Gas and oil Enter how much you spend each month on gas and oil for your car. Bus fare/parking fees Enter your monthly cost for bus fare or parking. Other (explain): Describe any other travel cost not already listed. Other (explain): Enter the monthly amount for that other travel cost. TOTAL: Add up all the transportation amounts above and write the total here. School and school supplies Enter your monthly cost for school and school supplies. School activities or fees Enter your monthly cost for school activities or fees. Extracurricular activities of child(ren) Enter your monthly cost for your children's activities outside of school, like sports or music. Church/contributions Enter how much you give to church or charity each month. Newspapers, magazines and books Enter your monthly cost for newspapers, magazines, and books. Barber and beauty shop Enter your monthly cost for haircuts and beauty shop visits. Life insurance (beneficiary: Write the name of the person who would get the life insurance payout. Life insurance (beneficiary: Enter how much you pay each month for life insurance. Disability insurance Enter how much you pay each month for disability insurance. 9. Recreation/entertainment Enter how much you spend each month on fun activities like movies, hobbies, or sports. 10. Child(ren)'s allowance(s) Enter how much money you give your children each month as an allowance. 11. Union/Professional dues Enter how much you pay each month for union membership or job-related professional groups. 12. Voluntary retirement contributions and savings deductions Enter the money you choose to put into retirement or savings each month, beyond what is required. 13. Family gifts Enter how much you spend each month on gifts for family members. 14. Pet Expenses Enter how much you spend each month on your pets, like food and vet care. 15. Cigarettes Enter how much you spend each month on cigarettes or tobacco. 16. Alcohol Enter how much you spend each month on alcohol. 17. Other (explain): Describe any other monthly expense that does not fit the categories above. 17. Other (explain): $ Enter the monthly cost for the other expense you described. TOTAL: $ Add up all the amounts on this page and write the total here. Creditor Name Write the name of the person or company you owe money to. Do not list expenses already on Item 7. Purpose of Debt Explain what the debt was for, like a car loan or credit card. Unpaid Balance Write how much you still owe on this debt right now. Min. Monthly Payment Write the smallest amount you must pay each month on this debt. Date of Your Last Payment Write the date you last made a payment on this debt. Amount of Your Payment Write how much you actually paid on this debt last time. Name Write the full name of the first person who lives in your home with you.

e. Children's Basic Information

Date of Birth Enter the birth date of this first household member. Relationship to you Say how this person is related to you, such as child, parent, or roommate. Income Enter how much money this person earns each month before taxes. Round to the nearest dollar. Name Write the full name of the second person who lives in your home with you. Date of Birth Enter the birth date of this second household member. Relationship to you Say how this person is related to you, such as child, parent, or roommate. Income Enter how much money this person earns each month before taxes. Round to the nearest dollar. H. Attorney's Fees paid in this matter $ Write the dollar amount you have paid a lawyer for this case. Source of funds Tell where the money came from to pay the lawyer, like savings or a loan. A. Your job/occupation/profession/title: Write the name of your job or the kind of work you do. Name and address of current employer: Write the name and full address of the place where you work now. Date employment began: Write the date you started working at your current job. Weekly Check this box if you get paid once every week. Every other week Check this box if you get paid once every two weeks. Monthly Check this box if you get paid once a month. Twice a month Check this box if you get paid two times each month. Other Check this box if your pay schedule is none of the listed choices. Other Explain how often you get paid if it is not one of the listed choices. B. If you are not working, why not? If you do not have a job, explain why, like illness or job loss. C. Previous employer name and address: Write the name and full address of the place you worked before this job. Previous job/occupation/profession/title: Write the kind of work you did at your last job. Date previous job began: Write the date you started your previous job. Date previous job ended: Write the date your previous job ended. Reason you left job: Tell why you stopped working at your last job. Gross monthly pay at previous job: $ Write how much you earned each month at your last job before taxes were taken out. Year Write the first of the last three years you filed taxes. $ Write your total income before taxes for that year. Year Write the second of the last three years you filed taxes. $ Write your total income before taxes for that year. Year Write the third of the last three years you filed taxes. $ Write your total income before taxes for that year. E. Your total gross income from January 1 of this year to the date of this Affidavit (year-to-date income): $ Write how much money you have earned before taxes from January 1 of this year until today. A. High School: Name the high school you went to, how long you attended, the last year you went, and whether you graduated. B. College: Name the college you attended, how long you went, the last year you were there, and any degree you earned. C. Post-Graduate: List any school you attended after college, how long, the last year, and any degree earned. D. Occupational Training: List any job or trade training you completed, how long it lasted, and any certificate you earned. A. Gross salary/wages per month Enter your total pay each month before taxes or other money is taken out. Rate of Pay $ Enter the dollar amount you are paid at your set rate, then check the box that shows the time period. [ ] hour Check this if the rate you wrote is what you earn for each hour worked. [ ] week Check this if the rate you wrote is what you earn each week. [ ] month Check this if the rate you wrote is what you earn each month. [ ] year Check this if the rate you wrote is what you earn for the whole year. 1. Automobile Enter the monthly value of a car your employer pays for, if any. 2. Auto expenses, such as gas, repairs, insurance Enter the monthly amount your employer pays for car costs like gas, repairs, or insurance. 3. Lodging Enter the monthly value of housing your employer pays for, if any. 4. Other (Explain) Describe any other costs your employer pays for that are not already listed. 4. Other (Explain) $ Enter the monthly dollar amount for the other employer-paid cost you described. C. Commissions/Bonuses Enter the monthly amount you earn from commissions or bonuses. Use a monthly average if it changes. D. Tips Enter the monthly amount you earn in tips. Use a monthly average if it changes. E. Self-employment Income (See below) Enter your monthly income from any business you run or work you do for yourself. F. Social Security benefits Enter the monthly amount you get from Social Security, if any. G. Worker's compensation and/or disability income Enter the monthly amount you get from workers' compensation or disability payments, if any. H. Unemployment compensation Enter the monthly amount you get from unemployment benefits, if any. I. Gifts/Prizes Enter the monthly amount you receive from gifts or prizes. Use a monthly average if it changes. J. Payments from prior spouse Enter the monthly amount you get from a former husband or wife, like alimony or spousal support. K. Rental income (net after expenses) Enter the money you make each month from renting out property, after you subtract the costs of owning it. L. Contributions to household living expense by others Enter the monthly amount others give you to help pay for your home and living costs, such as money from a roommate or partner. M. Other (Explain:) Briefly describe any other income not listed above, like dividends, pensions, interest, or royalties. M. Other (Explain:) $ Enter the monthly dollar amount for the other income you described. TOTAL: Add up all the income amounts in this section and write the total here. Name, address and telephone no. of business: Write the name, street address, and phone number of your business if you work for yourself. Type of business entity: State what kind of business this is, such as sole proprietor, partnership, LLC, or corporation. State and Date of incorporation: If your business is a corporation, write the state where it was formed and the date it started. Nature of your interest: Describe how you are involved in the business, like owner, partner, or shareholder. Nature of business: Briefly describe what the business does or sells. Percent ownership: Write what share of the business you own, shown as a percent. Number of shares of stock: If the business has stock, enter how many shares you own. Total issued and outstanding shares: Enter the total number of shares the business has given out to all owners. Gross sales/revenue last 12 months: Enter the total money the business took in over the past year, before any costs are subtracted.

f. Health & Medical Support

Drugs and medical supplies Enter how much you pay each month for drugs and medical supplies that insurance does not cover. Other Describe any other medical or dental costs you pay that insurance does not cover. Other Enter the monthly dollar amount for the other medical or dental cost you described. TOTAL: Add up the amounts above and write the total here. Total monthly child care costs Enter the total amount you pay each month for child care. Do not count any amount paid by D.E.S. YES Check this box if your job offers a pretax plan for child care costs and you use it. NO Check this box if you do not use an employer pretax plan for child care costs.

g. Child Support

Court ordered current child support for child(ren) not common to the parties Enter the monthly child support a court ordered you to pay for children who are not shared with the other party.

h. Health & Medical Support

Court ordered cash medical support for child(ren) not common to the parties Enter the monthly cash medical support a court ordered you to pay for children who are not shared with the other party. Amount of any arrears payment Enter how much you pay each month toward past-due support you owe. Amount per month actually paid in last 12 mos. Enter the amount you actually paid each month over the last 12 months. Attach proof that you are paying. Court ordered spousal maintenance/support you actually pay to previous spouse: Enter the monthly dollar amount you actually pay a former spouse for alimony, if a court ordered it. Leave blank if you pay none. For Children (Educational Expense/Special Needs/Other): Enter the monthly dollar amount you spend on unusual costs for your children, like special schooling or special needs care. Explain: Describe what the unusual children's expense is for, such as tutoring, therapy, or medical care. For Self: Enter the monthly dollar amount you spend on unusual costs for yourself that are not part of your normal living expenses. Explain: Describe what the unusual expense for yourself is for, so the court understands the cost. First Mortgage Enter how much you pay each month for your first home loan. Second Mortgage Enter how much you pay each month for a second home loan, if you have one. Homeowners Association Fee Enter your monthly homeowners association fee, if any. Rent Enter how much rent you pay each month if you do not own your home. Repair & upkeep Enter the average monthly cost to fix and maintain your home. Yard work/Pool/Pest Control Enter the monthly cost for lawn care, pool service, or pest control. Insurance & taxes not included in house payment Enter monthly home insurance and property taxes only if they are not already part of your house payment. Other (Explain): Describe any other housing cost not listed above. Other (Explain): Enter the monthly amount for the other housing cost you described. TOTAL: Add up all the housing amounts above and write the total here. Water, sewer, and garbage Enter your monthly cost for water, sewer, and trash service. Electricity Enter your average monthly electric bill. Gas Enter your average monthly gas bill, if you have one. Telephone Enter your monthly cost for home or landline phone service. Mobile phone/pager Enter your monthly cell phone or pager bill. Internet Provider Enter your monthly internet service cost. Cable/Satellite television Enter your monthly cable or satellite TV cost. Other (Explain): Describe any other utility cost not listed above. Other (Explain): Enter the monthly amount for the other utility you described. TOTAL: Add up all the utility amounts above and write the total here. Food, milk, and household supplies Enter how much you spend each month on groceries and home supplies. School lunches Enter the monthly cost of school lunches for your children. Meals outside home Enter how much you spend each month eating out or buying takeout. TOTAL: Add up all the food amounts above and write the total here. Clothing for you Enter how much you spend each month on clothes for yourself. Uniforms or special work clothes Enter your monthly cost for work uniforms or special clothes needed for your job. Clothing for children living with you Enter how much you spend each month on clothes for the children who live with you. Laundry and cleaning Enter your monthly cost for washing and dry cleaning clothes. TOTAL: Add up all the clothing amounts above and write the total here. Car insurance Enter how much you pay each month for car insurance. List all cars and individuals covered: List each car and the people covered by your car insurance. Car payment, if any Enter your monthly car loan or lease payment, if you have one. Car repair and maintenance Enter how much you spend each month on car repairs and upkeep. Gas and oil Enter your monthly cost for gas and oil for your car. Bus fare/parking fees Enter your monthly cost for bus fare or parking fees. Other (explain): Describe any other transportation cost not already listed. Other (explain): Enter the monthly amount for the other transportation cost you described. TOTAL: Add up all the transportation amounts above and write the total here. School and school supplies Enter your monthly cost for school and school supplies. School activities or fees Enter your monthly cost for school activities or fees. Extracurricular activities of child(ren) Enter your monthly cost for your children's activities outside of school, like sports or clubs. Church/contributions Enter how much you give each month to a church or other group. Newspapers, magazines and books Enter your monthly cost for newspapers, magazines, and books. Barber and beauty shop Enter your monthly cost for haircuts and beauty services. Life insurance (beneficiary: Write the name of the person who would receive your life insurance money. Life insurance (beneficiary: Enter how much you pay each month for life insurance. Disability insurance Enter how much you pay each month for disability insurance. 9. Recreation/entertainment Enter how much you spend each month on fun activities like movies, hobbies, or going out. 10. Child(ren)'s allowance(s) Enter how much money you give your children each month as an allowance. 11. Union/Professional dues Enter how much you pay each month for union or job-related membership fees. 12. Voluntary retirement contributions and savings deductions Enter how much you choose to put into retirement or savings each month from your pay. 13. Family gifts Enter how much you spend each month on gifts for family members. 14. Pet Expenses Enter how much you spend each month on your pets, like food and vet care. 15. Cigarettes Enter how much you spend each month on cigarettes or other tobacco. 16. Alcohol Enter how much you spend each month on alcohol. 17. Other (explain): Describe any other monthly expense not already listed above. 17. Other amount Enter how much you spend each month on the 'Other' expense you described. TOTAL: Add up all the amounts in this section and write the total here. Creditor Name Write the name of each person or company you owe money to. Purpose of Debt Explain what each debt was for, like a car loan or credit card. Unpaid Balance Write how much money you still owe on each debt. Min. Monthly Payment Write the smallest payment you must make each month for each debt. Date of Your Last Payment Write the date you last made a payment on each debt. Amount of Your Payment Write how much money your last payment was for each debt. EMPLOYER* NAME: Write the name of the company or person who pays this person. This is where the order will be sent. PAYROLL ADDRESS: Write the street address of the payroll or money department where the order should be mailed. CITY: Write the city for the employer's payroll address. STATE: Write the state for the employer's payroll address. ZIP: Write the ZIP code for the employer's payroll address. EMPLOYER* TELEPHONE: Write the phone number for the employer or payroll department. EMPLOYER* FAX: Write the fax number for the employer or payroll department if you know it.