1. (1) The Affidavit form in Paragraph (2) shall be completed by the custodial parent, the guardian, or other caretaker of the child and shall be used by the Clerk of the Court or by the Department of Human Services or its contractor for the purpose of supporting the issuance of an Income Withholding for Support (Order for Income Assignment) pursuant to Rule 1240- 02-02-.04. It will only be used in conjunction with the request of a custodial parent, a guardian, or other caretaker to whom child or spousal support was previously paid directly, because no Order for Income Assignment had been issued, for any reason, when the obligor of support is now alleged to be in arrears in the affidavit filed by the custodial parent, the guardian, or other caretaker of the child.
2. (2) Form: STATE OF TENNESSEE STATE OF TENNESSEE COUNTY OF __________________ AFFIDAVIT OF ARREARAGE First being duly sworn, affiant would state: I am _____________________________, <Custodial Parent/Guardian/Caretaker of the Child>. I do hereby swear or affirm that to the best of my knowledge, information and belief, as of ___________ <Date>, the Respondent, _________________________________, is in arrears for support in the total amount of $ ______________________, which was calculated as follows: Month ___________________Year _______________ Amount $____________________ Month ___________________Year _______________ Amount $____________________ Month ___________________Year _______________ Amount $____________________ Month ___________________Year _______________ Amount $____________________ Month ___________________Year _______________ Amount $____________________ Month ___________________Year _______________ Amount $____________________ Month ___________________Year _______________ Amount $____________________ Month ___________________Year _______________ Amount $____________________ Month ___________________Year _______________ Amount $____________________ Month ___________________Year _______________ Amount $____________________ Month ___________________Year _______________ Amount $____________________ Month ___________________Year _______________ Amount $____________________ __________________________________________ Name-Please Print __________________________________________ Signature __________________________________________ Date Further affiant sayeth not. Sworn to and subscribed before me this __________ day of _________________, ______. _______________________________________ Notary Public/Court Clerk My commission expires:_________________

Authority: T.C.A. §§4-5-202, 36-5-501, 71-1-132(c), 42 U.S.C. §§651 et seq., 42 U.S.C. §§652(a)(11), 654(9)(E), 654a(g)(1)(A)(ii) and 666(a)(8) and (b), 45 C.F.R. §§303.6(c)(1), 303.7, and 303.100. Administrative History: Original rule filed October 14, 1999; effective December 28, 1999. Amendment filed September 8, 2009; effective December 7, 2009.