AFFIDAVIT CONCERNING DEPENDENT CHILDREN AND HOUSEHOLD INCOME
Having been duly sworn, I, ____________________, depose and state the following to be true, accurate and complete:
Full legal name of child | Age | Child's gross monthly support and income |
_________________________ | ______ | ______________________________________________ |
_________________________ | ______ | ______________________________________________ |
_________________________ | ______ | ______________________________________________ |
_________________________ | ______ | ______________________________________________ |
(attach additional pages if necessary)
Full legal name of household residents | Gross monthly income |
__________________________________________ | _________________________ |
__________________________________________ | _________________________ |
__________________________________________ | _________________________ |
__________________________________________ | _________________________ |
(attach additional pages if necessary)
________________________________________ (signature of debtor)
____________________ (date)
Commonwealth of Virginia:
City/County of ____________________, to wit:
Subscribed and sworn to before me, the undersigned Notary Public, this __________ day of __________ (month), __________ (year)
Notary Public: ________________________________________
My commission expires: ____________________
Va. Code § 34-4.2