PP-110 7-1-08 STATE OF MAINE COUNTY PROBATE COURT DOCKET NO. In Re: STATEMENT CONCERNING PUBLIC ASSISTANCE I make the following statements (Check one statement in each section that applies.) 1. The child of the parties in this action: A. Has never received TANF or MaineCare. Neither party intends to file an application TANF or MaineCare for the child. B. Has received or is now receiving TANF or MaineCare. C. A party intends to file an application for TANF or MaineCare for the child. If B or C is checked, you must send a copy of the complaint or motion to the Department of Health and Human Services, Support Enforcement Division, Central Office Supervisor, State House Station 11, Augusta, ME 04333-0011. 2. Of the parties in this action: A. (Mother)(Father) is a support enforcement client of the Department of Health and Human Services or has requested the assistance of the Department in establishing, reviewing, modifying, or enforcing a child support order concerning the child. B. Neither party has contacted the Department of Health and Human Services for the establishment, review, modification, or enforcement of a child support order concerning the child. 3. The Department of Health and Human Services: A. Has not issued a child support order concerning the child. B. Has issued a child support order concerning the child. If B is checked, you must attach a copy of the order. Date: Signature of Petitioner Printed or Typed Name Address and phone number MARP American LegalNet, Inc. www.FormsWorkFlow.com