JV-023 (Rev. 06/10/2013)[Case Type: TS (Temporary Support)] COMPLAINT FOR A TEMPORARYORDER OF SUPPORTG.L. c. 119, 247 28 DOCKET NUMBER Trial Court of MassachusettsJuvenile Court Department 1. Plaintiff, , who resides at is(print or type full name)Signature of Attorney, or Plaintiff, if pro seAddress This matter shall be heard in conjunction with the petition filed pursuant to G. L. c. 119, 247 24.Date: (street and no.)(city or town)(county)(state)(zip code)childmotherfatherguardian/custodianparent/personal representative of the mother/father of the childthe Department of Children and Families/agency licensed under G. L. c. 28Athe Department of Transitional Assistance/Department of Revenue2. The child for whom support is sought:(social security number)(date of birth)(name)(zip code)(state)(county)(city or town)(street and no.)3. Defendant(s) is/are: Name: Address: DOB: SSN: Relationship to child:4. Are the child's mother and father currently married to each other? Yes No If no, are mother and father divorced or separated? Yes No5. If the answers to Question No. 4 are no, has paternity been adjudicated? Yes No If yes, date paternity was adjudicated Court6. Who has custody of the child?7. A copy of the child's birth certificate is attached. WHEREFORE, the plaintiff requests that the Court: order a suitable amount of support for said child. order the defendant to maintain/provide health insurance for the benefit of the child. DIVISION Telephone No. BBO No. American LegalNet, Inc. www.FormsWorkFlow.com