GENERAL TESTIMONY IV-D Case: Petitioner Respondent Non-IV-D Case: [ [ [ [ [ [ ] ] ] ] ] ] TANF IV-E Foster Care Medicaid Only Former Assistance Never Assistance File Stamp Responding IV-D Case No. _________________________________ Initiating IV -D Case No. _______________________________ Responding Tribunal No. ____________________________________ Initiating Tribunal No. _________________________________ [ ] Obligee [ ] Foster Care [ ] Obligee [ ] Caretaker Other than Parent [ ] Obligor Respondent is: [ ] Caretaker Other than Parent [ ] Obligor Petitioner is: [ ] Foster Care _______ ____________________________________________ being duly sworn, under penalties of perjury, testifies as follows: Name (First, Middle, Last) I. Personal Information About Child(ren)'s Mother A.1. Mother is: [ ] Obligee [ ] Obligor 2. [ ] See Section X [ ] Nondisclosure Finding Attached 3. Full Name (First, Mid, Last) Nickname, alias, maiden name, former married name, etc. [ ] Confirmed______________(date) 9. Employer Name & Address [ ] Confirmed_________(date) 5. Social Security Number 6. Date of Birth 7. Home Phone ( ) 4. Home Address 8. Work Phone ( ) 10(a). Occupation, Trade or Profession 10(b). Highest Level Of Education Attained 11. Estimated Gross Monthly Earnings $ 12. Other Monthly Income (& source) $ 13. Real or Personal Property (type & location) B. Physical Description of Child(ren)'s Mother (Attach photo if available.) 1. Race 2. Height 3. Weight 4. Hair Color 5. Eye Color C. Present Marital Status of Child(ren)'s Mother 1. [ ] Married 2. [ ] Single 3. [ ] Living with Non-Marital Partner 4. [ ] Divorced 5. [ ] Legally Separated 6. [ ] Separated General Testimony 7. [ ] Unknown OMB No. 0970 - 0085 Expiration Date: 01/31/2008 Page 1 of 10 American LegalNet, Inc. www.USCourtForms.com GENERAL TESTIMONY, PAGE 2 Initiating IV-D Case No. D. Information about Current Spouse or Partner of Child(ren)'s Mother 1. Name of Current Spouse or Partner 2. Is Current Spouse/Partner Employed? (First, Mid, Last) [ ] Yes 3. Name and Address of Spouse's/Partner's Employer [ ] No [ ] Unknown 4. Spouse's/Partner's Estimated Gross Monthly Earnings $ E. Is the child(ren)'s mother responsible for dependents other than those listed in Section V (pages 4 & 5)? [ ] Yes 1. [ ] No [ ] Unknown (If yes, provide information below.) b. Date of Birth a. Full Name (First, Mid, Last) c. Relationship e. Source of Support/Income 2. d. Living With: f. Monthly Amount; Gross: a. Full Name (First, Mid, Last) b. Date of Birth c. Relationship d. Living With: e. Source of Support/Income 3. Net: f. Monthly Amount; Gross: a. Full Name (First, Mid, Last) Net: b. Date of Birth c. Relationship d. Living With: e. Source of Support/Income f. Monthly Amount; Gross: II. Personal Information About Child(ren)'s Father A.1. Father is: [ ] Obligee [ ] Obligor 2. Net: [ ] See Section X [ ] Nondisclosure Finding Attached 3. Full Name (First, Mid, Last) Nickname, Alias [ ] Confirmed______________(date) 9. Employer Name & Address [ ] Confirmed_________(date) 5. Social Security Number 6. Date of Birth 7. Home Phone ( ) 4. Home Address 8. Work Phone ( ) 10(a). Occupation, Trade or Profession 10(b). Highest Level Of Education Attained 11. Estimated Gross Monthly Earnings $ 12. Other Monthly Income (& source) $ 13. Real or Personal Property (type & location) B. Physical Description of Child(ren)'s Father (Attach photo if available.) 1. R ace General Testimony 2. Height 3. Weight 4. Hair Color 5. Eye Color Page 2 of 10 American LegalNet, Inc. www.USCourtForms.com GENERAL TESTIMONY, PAGE 3 Initiating IV-D Case No. C. Present Marital Status of Child(ren)'s Father 1. [ ] Married 2. [ ] Single 3. [ ] Living with Non-Marital Partner 4. [ ] Divorced 5. [ ] Legally Separated 6. [ ] Separated 7. [ ] Unknown D. Information about Current Spouse or Partner of Child(ren)'s Father 1. Name of Current Spouse or Partner 2. Is Current Spouse/Partner Employed? (First, Mid, Last) [ ] Yes 3. Name and Address of Spouse's/Partner's Employer [ ] No [ ] Unknown 4. Spouse's/Partner's Estimated Gross Monthly Earnings $ E. Is the child(ren)'s father responsible for dependents other than those listed in Section V (pages 4 & 5)? [ ] Yes [ ] No [ ] Unknown (If yes, provide information below.) 1. b. Date of Birth a. Full Name (First, Mid, Last) c. Relationship e. Source of Support/Income 2. d. Living With: f. Monthly Amount; Gross: a. Full Name (First, Mid, Last) b. Date of Birth c. Relationship d. Living With: e. Source of Support/Income 3. Net: f. Monthly Amount; Gross: a. Full Name (First, Mid, Last) Net: b. Date of Birth c. Relationship d. Living With: e. Source of Support/Income f. Monthly Amount; Gross: Net: III. Personal Information About Caretaker Other than Parent 1. Caretaker's Relation to Child is: [ ] Has legal custody/guardianship of child 2. [ ] See Section X [ ] Nondisclosure Finding Attached 3. Full Name (First, Mid, Last) Nickname, alias, maiden name, former married name, etc. [ ] Confirmed____________(date) 10. Employer Name & Address [ ] Confirmed_______(date) 5. Social Security Number 6. Date of Birth 8. Home Phone ( ) 4. Home Address 7. Sex 9. Work Phone ( ) 11(a). Occupation, Trade or Profession 11(b). Highest Level Of Education Attained 12. Estimated Gross Monthly Earnings $ 13. Other Monthly Income (& source) $ 14. Date Child(ren) Began Residing With Caretaker General Testimony Page 3 of 10 American LegalNet, Inc. www.USCourtForms.com GENERAL TESTIMONY, PAGE 4 Initiating IV-D Case No. IV. Legal Relationship of Parents 1. [ ] Never married to each other [ ] See Section X 2. [ ] Married on _______________________in ____________________________ Date County/State 3. [ ] Married by common law for the period __________________________in__________________________________ Dates 4. [ ] Separated on _______________ County/State 5. [ ] Divorced on ________________in_____________________________ Date Date County/State 6. [ ] Legally separated on___________________in________________________________ Date County/State 7. [ ] Divorce pending in_____________________________ 8. [ ] Support Order Entered on ____________________ County/State 9. [ ] No support order Date 10. [ ] Other_______________________________________________________ 11. Tribunal & Location (Divorce, Legal Separation, Support Order): V. Dependent Child(ren) in this Action [ ] See Section X A. List obligor's (named on page 1 of this form) child(ren) only. [ ] Nondisclosure Finding Attached 1. b. Address c. Social Security Number g. Support Order Established? [ ] Yes [ ] No d. Sex 2. f. Paternity Established? [ ] Yes (check how) [ ] No [ ] By order [ ] By voluntary acknowledgment [ ] By adoption [ ] By conclusive marital presumption [ ] Other: h. Living with Petitioner? [ ] Yes [ ] No a. Full Legal Name (First, Mid, Last) e. Date of Birth b. Address c. Social Security Number g. Support Order Established? [ ] Yes [ ] No d. Sex 3. f. Paternity Established? [ ] Yes (check how) [ ] No [ ] By order [ ] By voluntary acknowledgment [ ] By adoption [ ] By conclusive marital presumption [ ] Other: h. Living with Petitioner? [ ] Yes [ ] No a. Full Legal Name (First, Mid, Last) e. Date of Birth b. Address f. Paternity Established? [ ] Yes (check how) [ ] No [ ] By order [ ] By voluntary acknowledgment [ ] By adoption [ ] By conclusive marital presumption [ ] Other: c. Social Security Number g. Support Order Established? [ ] Yes [ ] No d. Sex h. Living with Petitioner? [ ] Yes [ ] No a. Full Legal Name (First, Mid, Last) General Testimony e. Date of Birth Page 4 of 10 American LegalNet, Inc. www.USCourtForms.com GENERAL TESTIMONY, PAGE 5 4. Initiating IV-D Case No. b. Address f. Paternity Established? [ ] Yes (check how) [ ] No [ ] By order [ ] By voluntary acknowledgment [ ] By adoption [ ] By conclusive marital presumption [ ] Other: c. Social Security Number g. Support Order Established? [ ] Yes [ ] No d. Sex h. Living with Petitioner? [ ] Yes [ ] No a. Full Legal Name (First, Mid, Last) e. Date of Birth B. The child(ren) began residing in ___________________________ on ____________________________. State Month/Year VI. Medical Insurance [ ] See Section X 1. Is obligor required by a child support order to provide medical insurance for the child(ren)? [ ] Yes [ ] No 2. Is obligor required by a child support order to provide medical insurance for the obligee? [ ] Yes [ ] No 3. Medical coverage for dependent child(ren) listed in Section V and/or the obligee is provided by: For dependent child(ren) For obligee Obligee [ ] [ ] Obligor [ ] [ ] State Medicaid [ ] [ ] Obligee's Insurance Company: Policy Number: Obligor's Insurance Company: Obligee's Employer [ ] [ ] Obligor's Employer [ ] [ ] Other _________________ [ ] [ ] Policy Number: Other Insurance Company: Unknown [ ] [ ] No Coverage [ ] [ ] Policy Number: 4. The monthly cost paid by the obligee for medical insurance for the obligor's child(ren) only is: (If medical insurance is provided by the obligee or obligee's employer, skip to number 6). $____________________ 5. Obligee can purchase needed medical insurance at a monthly cost of: $____________________ 6. Were the children ever covered by medical insurance provided by the obligor/obligee, or his/her current employer? [ ] Yes [ ] No [ ] Unknown 7. Do any of the obligor's children have special needs or extraordinary medical expenses not covered by insurance? [ ] Yes [ ] No (If "Yes", please indicate the child involved and the type of special needs/extraordinary medical expenses and the related costs. Attach proof.) 8. Is the obligee asking to be reimbursed for medical coverage by obligor? [ ] Yes General Testimony [ ] No [ ] Unknown Page 5 of 10 American LegalNet, Inc. www.USCourtForms.com GENERAL TESTIMONY, PAGE 6 Initiating IV-D Case No. VII. Support Order and Payment Information [ ] See Section X [ ] Yes 1. Does a support order exist? (If "No", skip to page 7.) [ ] No 2. Did child(ren) reside with the obligor at anytime during the period for which support is sought, except during periods of visitation specified by a tribunal's order? [ ] Yes [ ] No If "Yes", Identify Period of Residency: From: Thru: 3. If a modification is being requested, indicate the basis for the request below: [ ] The earnings of the obligor have substantially increased or decreased. [ ] The earnings of the obligee have substantially increased or decreased. [ ] The needs of a party or of the child(ren) have substantially increased or decreased. [ ] Other, Explain ______________________________________________________________________________ 4. Describe all current support orders (include all pertinent orders and modifications). NOTE: if more than three (3) orders exist, attach complete description as below for each. Date of Order Current Amount $ Unpaid Interest $ as of Per Month/Week/etc. (date) Toward Arrears $ Total Arrears $ Per Month/Week/etc. as of (date) Tribunal's Name & Address Date of Order Current Amount $ Unpaid Interest $ as of Per Month/Week/etc. (date) Toward Arrears $ Total Arrears $ Per Month/Week/etc. as of (date) Tribunal's Name & Address Date of Order Current Amount $ Unpaid Interest $ as of Per Month/Week/etc. (date) Toward Arrears $ Total Arrears $ Per Month/Week/etc. as of (date) Tribunal's Name & Address 5. Unpaid Medical Cost Reimbursement (attach documentation) $____________________ 6. Other Unpaid Costs and Fees $____________________ as of _________________________ Date as of _________________________ Date Explain: ______________________________________________________________________________________________ 7. Direct Payments to Obligee: [ ] Affidavit from Obligee Attached [ ] No Direct Payments Received 8. Obligor's support payment history: [ ] Certified copy of tribunal/agency payment [ ] Payment history provided on page 6a. history is attached. (Skip to page 7). From (Year) to (Year): General Testimony [ ] N.A.; responding State does not require. (Skip to page 7). Agency Which Prepared Audit/Payment History: Page 6 of 10 American LegalNet, Inc. www.USCourtForms.com GENERAL TESTIMONY, PAGE 6a Obligor's Payment History Initiating IV-D Case No. Adjudicated Arrears $____________________ as of ____________________ Date of Order Year: ______________________ Amount Due Amount Paid Balance Year: ______________________ Amount Due Amount Paid Balance Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total Year: ______________________ Amount Due Amount Paid Balance Year: ______________________ Amount Due Amount Paid Balance Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total Total of Adjudicated and Accrued Arrears $_____________________ as of ___________________________ ________________________ Date ________________________ Sworn to and Signed before me this Date, County, State General Testimony __________________________________________ ____________________________________ Name/Title, Agency or Tribunal Signature __________________________________________ ____________________________________ Notary Public Official and Title Commission Expires Page 6a of 10 American LegalNet, Inc. www.USCourtForms.com GENERAL TESTIMONY, PAGE 7 Initiating IV-D Case No. [ ] VIII. TANF / Foster Care/Medical Assistance Status See Section X [If no TANF/Foster Care/Medical Assistance benefits were paid, skip to Section IX.] 1. Period during which TANF/Foster Care was paid: From:_______________/__________ To:_______________/__________by:____________________________ First month year Last month 2. Total amount of TANF/Foster Care paid: year State $______________________ as of ___________________________ Date 3. Medical assistance related to prenatal, postnatal, or general expenses was paid in the amount of $_____________ by: _______________________________________________________________________________. Agency or Person IX. Financial Information [ ] See Section X Information required varies based on responding State's guidelines. Updates may be required. A. Monthly Income from All Sources: 1. Is the petitioner employed? [ ] Yes; occupation:___________________ [ ] No; income source:_________________ 2. Gross Monthly Income Amounts: a) Public Assistance i) SSI ii) Family Assistance iii) Other b) Base pay salary, wages c) Overtime, commissions, tips, bonuses, parttime Petitioner Current Spouse/Partner Obligor's Dependent(s) $_______________ $_______________ $_______________ $_______________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $_______________ $________________ $________________ d) Unemployment compensation $_______________ $________________ $________________ e) Worker's compensation $_______________ $________________ $________________ f) Social Security Disability $_______________ $________________ $________________ g) Social Security Retirement $_______________ $________________ $________________ h) Dividends and interest $_______________ $________________ $________________ i) Trust/Annuity Income $_______________ $________________ $________________ j) Pensions,retirement $_______________ $________________ $________________ k) Child support $_______________ $________________ $________________ l) Spousal support/alimony $_______________ $________________ $________________ $_______________ $________________ $________________ m) All other sources Explain "other sources":____________________________________________________________________ 3. Total Gross Monthly (lines "2a" through "2m") 4. Deductions From Gross a) Federal Income Tax b) State Income Tax c) Local Tax d) F.I.C.A. General Testimony $_______________ $________________ $________________ $_______________ $_______________ $_______________ $_______________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ Page 7 of 10 American LegalNet, Inc. www.USCourtForms.com GENERAL TESTIMONY, PAGE 8 Petitioner 5. Adjusted Net Monthly Initiating IV-D Case No. Current Spouse/Partner Obligor's Dependent(s) $_______________ $________________ $________________ a) Savings $_______________ $________________ $________________ b) Loan Repayment $_______________ $________________ $________________ c) Mandatory Retirement $_______________ $________________ $________________ d) Non-mandatory Retirement $_______________ $________________ $________________ e) Medical Insurance $_______________ $________________ $________________ f) Union Dues $_______________ $________________ $________________ g) Other (specify) $_______________ $________________ $________________ (lines "3" minus lines "4a through 4d") 6. Other Deductions 7. Net Monthly Income (line 5 minus lines "6a through 6g") $________________ $________________ $_________________ 8. Gross Income Prior Year $________________ $________________ $________________ Attach three most recent paystubs from each current employer for all parties shown. B. Monthly Expenses Petitioner Obligor’s Dependents 1) Rent/Mortgage 2) Homeowners/Renters Insurance 3) Hom Maintenance & Repair e 4) Heat 5) Electricity/Gas 6) Telephone 7) Water/Sewer 8) Food 9) Laundry/Cleaning 10)Clothing 11) Life Insurance 12) Medical Insurance 13) Uninsured Extraordinary Medical (attach documentation) 14) Other Uninsured Health-Related Expenses 15) Auto Payment 16) Auto Insurance 17) Auto Expenses 18) Other Transportation 19) Child Care $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ Provider:__________________________ Frequency_____________ ________ Per 20) Support Paym ents, actual amount paid 21) Internet service 22) Other; Explain $__________ $__________ $__________ $__________ $__________ $__________ Total Monthly Expenses (lines 1 through 22) $__________ $__________ General Testimony Page 8 of 10 American LegalNet, Inc. www.USCourtForms.com GENERAL TESTIMONY, PAGE 9 Initiating IV-D Case No. C. Assets: 1) Real Estate ____________________________________________________________________ Address ____________________________________________________________________ Ow ner(s) ____________________________________________________________________ Title $__________________________ minus $_________________________ = Assessed Value $_________________ Mortgage(s) 2) IRA, Keogh, Pension, Profit Sharing, Other Retirement Plans _______________________________________________________________________________ $_________________ Institution or Plan Name and Account No. _______________________________________________________________________________ $_________________ Institution or Plan Name and Account No. 3) Tax Deferred Annuity Plan(s) $_________________ 4) Life Insurance: Present Cash Value $_________________ 5) Savings & Checking Accounts, Money Market Accounts, & CDs $_________________ _______________________________________________________________________________ Institution Name and Account Number _______________________________________________________________________________ $_________________ Institution Name and Account Number 6) Automobiles/Vehicles _______________ _______________ __________ $_____________ minus $____________ = $_____________ Make Model Year Estimated Value Loan Balance _______________ _______________ __________ $_____________ minus $____________ = $_____________ Make Model Year Estimated Value Loan Balance _______________ _______________ __________ $_____________ minus $____________ = $_____________ Make Model Year 7) Other (e.g., Personal Property, Securities, etc). Total Assets (lines 1 through 7) General Testimony Estimated Value Loan Balance Describe: __________________ $_____________ $_____________ Page 9 of 10 American LegalNet, Inc. www.USCourtForms.com GENERAL TESTIMONY, PAGE 10 X. Other Pertinent Information Initiating IV-D Case No. (Attach additional sheets if necessary). XI. Verification [ ] Attached are the required number of copies of all support orders for the case. Also attached and incorporated by reference are: [ ] Copy of the certified child support payment records. [ ] Copies of three most recent paystubs from current employer. [ ] Copies of bills for prenatal, postnatal and general health care of mother and child. [ ] Assignment or subrogation of support rights. [ ] "Affidavit in Support of Establishing Paternity" for each child whose paternity is at issue. [ ] Copy of child(ren)'s birth certificate(s). [ ] Acknowledgment of parentage. [ ] Documentation of legal custody/guardianship of child(ren). [ ] Documentation that children are in foster care. [ ] Other:________________________________________________________________________________________ All of the information and facts contained in this General Testimony are true and correct to my/our best knowledge and belief. ______________________ Date ______________________ Date ______________________ Sworn to and Signed Before me This Date County/State General Testimony _________________________________________ Petitioner (Name/Title) _________________________________________ Agency Representative (Name/Title) _________________________________________ Notary Public, Tribunal/Agency Official and Title _____________________________ Signature _____________________________ Signature _____________________________ Commission Expires Page 10 of 10 American LegalNet, Inc. www.USCourtForms.com