SUPERIOR COURT OF THE DISTRICT OF COLUMBIA FAMILY COURT Paternity & Support Branch ________________________________________ PRINT YOUR NAME ________________________________________ STREET ADDRESS ________________________________________ CITY, STATE AND ZIP CODE SUBSTITUTE ADDRESS: CHECK BOX IF YOU HAVE WRITTEN SOMEONE ELSE’S ADDRESS BECAUSE YOU FEAR HARASSMENT OR HARM. PETITIONER, v. PS _____________________ IV-D _____________________ Related Cases: _____________________________ _____________________________ ________________________________________ PRINT THE OTHER PARENT’S NAME ________________________________________ STREET ADDRESS ________________________________________ CITY, STATE AND ZIP CODE RESPONDENT. PETITION TO ESTABLISH PATERNITY and/or FOR CHILD SUPPORT Are You Asking the Court to Decide Paternity? yes no I, _________________________________, am the Petitioner in this case and state that PRINT YOUR NAME 1. This Court has the authority to decide my request for establishing paternity and/or child support. DC Bar Pro Bono Program (revised 9-2011) Petition to Establish Paternity and/or For Child Support Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com 2. I am seeking support for the following child(ren) that I have with Respondent (through birth or adoption): Child’s Name Current Address Date of Birth Gender 3. I state the following about paternity [CHECK ALL THAT APPLY] The child(ren) were born during my marriage to Respondent. The Respondent is named on the child(ren)’s birth certificate(s). The Respondent and I have both signed a written statement under oath admitting paternity. The Respondent has signed a written statement admitting paternity. Another state has decided paternity. There is a genetic test result and a certified affidavit from a laboratory indicating a 99% or greater probability that the Respondent is the father. Other ______________________________________________________________ ________________________________________________________________________ 4. The Respondent has the legal duty to contribute to the support of our eligible child(ren), including any adult disabled children. DC Bar Pro Bono Program (revised 9-2011) Petition to Establish Paternity and/or For Child Support Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com 5. I state the following about Temporary Assistance to Needy Families (TANF): [CHECK ONE] I am currently receiving Temporary Assistance to Needy Families (TANF). I am not currently receiving Temporary Assistance to Needy Families (TANF). 6. I state the following about Medicaid and DC Healthy Families: [CHECK ONE] I am currently receiving Medicaid and/or DC Healthy Families. I am not currently receiving Medicaid and/or DC Healthy Families. Request for Relief I RESPECTFULLY REQUEST that [CHECK ALL THAT APPLY] The Court hold a hearing on this Petition within 45 days of filing and issue a Notice of Hearing and Order Directing Appearance (“NHODA”) to Respondent with the date and time of the hearing. The Court decide paternity for my child(ren) and order entry of the father’s name on the birth certificate for the child(ren). The Court award support according to the Child Support Guideline of the District of Columbia and other applicable laws, including: current child support (support starting today and continuing into the future) retroactive child support (support for time before today) medical support The Court order ______________________________________________________ ________________________________________________________________________ _______________________________________________________________________. PRINT ANYTHING ELSE YOU WANT THIS COURT TO DO. I ALSO REQUEST that the Court award any other relief it considers fair and proper. DC Bar Pro Bono Program (revised 9-2011) Petition to Establish Paternity and/or For Child Support Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com [CHECK ONE] I do not know of any proceedings in the District of Columbia or in any state or territory involving the same claim or subject matter as this case. I do know of proceedings in the District of Columbia or in any state or territory involving the same claim or subject matter as this case, as listed on the first page of this Petition (“Related Cases”). Respectfully Submitted, ____________________________________ SIGN YOUR NAME ___________________________________________ STREET ADDRESS ___________________________________________ CITY, STATE AND ZIP CODE ___________________________________________ TELEPHONE NUMBER SUBSTITUTE ADDRESS: CHECK BOX IF YOU HAVE WRITTEN SOMEONE ELSE’S ADDRESS BECAUSE YOU FEAR HARASSMENT OR HARM. I, _________________________________, solemnly swear or affirm under criminal penalties for the making of a false statement that I have read the foregoing Petition to Establish Paternity and/or For Child Support and that the factual statements made in it are true to the best of my personal knowledge, information and belief. ___________________________________ ______________________________ SIGN YOUR NAME DATE ___________________________________ PRINT YOUR NAME DC Bar Pro Bono Program (revised 9-2011) Petition to Establish Paternity and/or For Child Support Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com