The following form may be used with the Petition to Set Support and Petition for Modification found in Rule 1240-02-01-.01(1) and (2). Where the petition language indicates a choice between Petitioner or Respondent, circle the appropriate choice. IN THE _____________ COURT OF ______________ COUNTY, TENNESSEE STATE OF TENNESSEE ex. rel., _____________________________________ Docket No. ________________ Petitioner

1. v. IV-D No. ________________ _____________________________________ Respondent AFFIDAVIT Comes the Petitioner / Respondent, and being first duly sworn, states (select all that apply and fill in the blanks):
2. 1. The child(ren) named in the petition reside with me: _____ less than 50% of the time _____ exactly 50% of the time _____ more than 50% of the time
3. 2. _____ I am married to the petitioner / respondent, but we are living separately. _____ I have never been married to the petitioner/ respondent. _____ I am divorced from the petitioner / respondent by order of the _________ Court of _______ County, ______ (state), Docket number _______________, effective date ____________.
4. 3. The child(ren) spend _______ (number) days per month/year with the respondent, with each day being more than twelve (12) consecutive hours in a twenty-four (24) hour period.
5. 4. _____ There is not an order for the support of the child(ren). _____ The most recent order for support of the child(ren) is from the _________ Court of _________ County, ______ (state), Docket number _______________, effective date ______________, in the amount of $________ per month.
6. 5. I pay for the child(ren)’s medical insurance, at a cost of $________ monthly.
7. 6. I pay for the child(ren)’s dental insurance, at a cost of $________ monthly.
8. 7. I pay for work-related child care for the child(ren) at a cost of $________ monthly.
9. 8. The deductible or co- pay for the child(ren)’s medical care is $_________ per _______________________ (visit, month, annual).
10. 9. I pay $_____________ per month for the child(ren)’s recurring medical expenses.
11. 10. The child(ren) participate in the following enriching and/or extracurricular activities at a cost of $_________ monthly: ________________________________________________ ________________________________________________________________________
12. 11. The child(ren) incur the following educational expenses at an average monthly cost of $___________ : ___________________________________________________________ ________________________________________________________________________
13. 12. My average gross monthly income from all non-exempt sources is $___________.
14. 13. I am the legal parent of _____ (number) other qualified minor children who live in my home 50% of the time or more.
15. 14. I am the legal parent of _____ (number) of minor children who live in my home less than 50% of the time. Over the last 12 months I have provided support for these children in the average amount of $_________ monthly. ___________________________________ Petitioner / Respondent Sworn to and subscribed before me this ____ day of ___________________, 20___. ____________________________________ NOTARY PUBLIC / CLERK My commission expires: _________________

Authority: T.C.A. §36-5-406. Administrative History: New rule filed December 17, 1985; effective January 14, 1986. Amendment filed March 24, 2009; effective June 7, 2009.