LR8-Form 12

STATE OF NEW MEXICO
EIGHTH JUDICIAL DISTRICT COURT
COUNTY OF ___________________

______________________,
Petitioner,

v.                                No. ____________

______________________,
Respondent.

TEMPORARY DOMESTIC ORDER AFFIDAVIT

STATE OF NEW MEXICO )
                 ) ss.
COUNTY OF _________ )

Petitioner's Statement of Monthly Income

(To be filled in by Petitioner)

1.    GROSS monthly salary or wages of Petitioner
    (hourly wage x average hours worked per
    week x 52 divided by 12; weekly wage x 52
    divided by 12; biweekly wage x 26 divided
    by 12; semi-monthly x 2, etc.; for varying
    wages, average last six months' income)        $_________

2.    Other Income (Identify: rental: $________;
    self-employment:              $________;
    other                     $________    $_________

3.    Deductions per month:

    Federal withholding:                    $_________

    Number of exemptions claimed (Form W4) _____

    Marital status (Form W4) single ______
                     married _____

    State withholding:

$_________

    FICA:

$_________

    Health insurance premium for children
    or family:

$_________

    Union dues:

$_________

    Other (identify): ________________

$_________

4.    Net monthly income

$_________

Petitioner's Statement of

Fixed Monthly Debts of Both Parties

        (State who is paying which debt at the time of the affidavit)

(To be filled in by petitioner)

                                    Husband         Wife
5.    House, apartment or other residence    
    monthly payment:                    $_________    $________

6.    Vehicle payment:

     Make     Creditor     Payment

a)    __________ ____________ $__________     __________    __________
b)    __________ ____________ $__________     __________    __________
c)    __________ ____________ $__________     __________    __________

7.    Minimum monthly payments
    on credit cards:

    Creditor             Payment

a)    ________________________ $__________     __________     __________
b)    ________________________ $__________     __________     __________
c)    ________________________ $__________     __________     __________
d)    ________________________ $__________     __________     __________
e)    ________________________ $__________     __________     __________
f)    ________________________ $__________     __________     __________

8.    Monthly payment on other loans:

    Creditor             Payment

a)    ________________________ $__________     __________     __________
b)    ________________________ $__________     __________     __________
c)    ________________________ $__________     __________     __________

9.    Vehicle insurance on monthly basis:     __________     __________

10.    Child support to another family:         __________     __________

11.    Day care for this family:             __________     __________

12.    Other (identify): _________________     __________     __________

13.                            TOTAL    $__________    $__________

Respondent's Statement of Monthly Income

(To be filled in by Respondent)

14.    GROSS monthly salary or wages of Respondent

    (hourly wage x average hours worked per week x 52 divided by 12; weekly wage x 52 divided by 12; bi-weekly wage x 26 divided by 12; semi-monthly x 2, etc.; for varying wages, average last six months' income)        $__________

15.    Other Income (identify: rental:         $________;
    self-employment: $________; other $________) _________

16.    Deductions per month:

    Federal withholding:

$___________

    Number of exemptions claimed (Form W4) _____
    Marital status (Form W4) single ______
                     married _____

    State withholding:

$___________

    FICA:

$___________

    Health insurance premium for children
    or family:

$___________

    Union Dues:

$___________

    Other (identify): ___________________

$___________

17.    Net monthly income

$___________

Respondent's Statement of Fixed Monthly Debts of Both Parties

(State who is paying which debt at the time of the Affidavit)

(To be filled in by respondent)

                                     Husband     Wife

18.    House, apartment or other residence
    monthly payment:                    $__________    $__________

19.    Vehicle payment:

    Make         Creditor     Payment
a)    __________ ____________    $__________     __________     __________

b)    __________ ____________    $__________     __________     __________
c)    __________ ____________    $__________     __________     __________

20.    Minimum monthly payments on credit cards:

    Creditor             Payment

a)    ________________________ $__________     __________     __________
b)    ________________________ $__________     __________     __________
c)    __________ ____________     $__________     __________     __________

d)    ________________________ $__________     __________     __________
e)    ________________________ $__________     __________     __________
f)    ________________________ $__________     __________     __________

21.    Monthly payment on other loans:

    Creditor             Payment

a)    ________________________ $__________     __________     __________
b)    ________________________ $__________     __________     __________
c)    ________________________ $__________     __________     __________

22.    Vehicle insurance on monthly basis:     __________     __________

23.    Child support to another family:         __________     __________

24.    Day care for this family:             __________     __________

25.    Other (identify): _________________     __________     __________

26.                            TOTAL    $__________    $__________            

    I swear, under penalty of perjury, that my statements in Petitioner's Statement of Income and Fixed Debts are true to the best of my knowledge.
                                                                 ____________________________________
                    Petitioner

    Subscribed and sworn to before me this _____ day of _____________,    ________, by ____________________________.
                                            
                    __________________________________

                    Notary Public

My commission expires:_____________________.

    I swear, under penalty of perjury, that my statements in Respondent's Statement of Income and Fixed Debts are true to the best of my knowledge.
                                                                 ____________________________________
                    Respondent

    Subscribed and sworn to before me this _____ day of _____________, _______, by ____________________________.

                    ____________________________________
                    Notary Public

My commission expires:_____________________.

USE NOTE

    A TDO shall be effective upon filing, and shall not require a judge's signature.

    The parties to a domestic relations cause shall be bound by any TDO filed.

[Rule 13, approved, effective January 1, 1991; LR8-108A NMRA; as amended, provisionally and recompiled, effective July 1, 2000 until statewide domestic rules and forms are adopted by the Supreme Court.]