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OBLIGOR/OBLIGEE CASE NUMBER
________________________________ 05- -DR- -XXXX-XX
AFFIDAVIT REGARDING DIRECT PAYMENTS
I, ________________________________, the above named Obligor Obligee,
under penalty of perjury, do hereby swear and/or affirm that I received paid direct the
following payments on the dates indicated:
PAYMENT DATE PAYMENT AMOUNT
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The total amount received paid (as evidenced by copies of cancelled checks) through
direct payment is $______________.
Neither of the parties hereto have previously received any monies from the Aid to
Families with
Dependent Children (AFDC) program.
Dated this _______ day of __________________, 20___.
________________________________ ________________________________
Affiant’s Signature Printed Name
_______________________________
________
________________________________
Address
Phone Number
Sworn to and subscribed before me this _______ day of __________________, 20___.
________________________________
Notary Public/Deputy Clerk
Law 422 / 20190430
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