UNIFORM SUPPORT PETITION Petitioner Name IV-D Case: Respondent Name 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. I. Action The Respondent and/or the Respondent's property is subject to the jurisdiction of the responding tribunal. The Respondent owes a duty of support to the following child(ren): Full Legal Name(First, Middle, Last) Date of Birth Social Security No. The Petitioner files this Petition to request (check all that apply): [ ] [ ] Establishment of Paternity Establishment of Order for: [ [ [ [ [ [ ] [ ] [ ] ] ] ] ] ] Current Child Support, Including Medical Support Retroactive Child Support Medical Support Only Spousal Support Costs and Fees Modification of a Support Order Determination of Controlling Order and Arrears Reconciliation Other Remedy Sought: II. Grounds Supporting the Remedy Sought in Section I (when applicable) [ ] Respondent is the noncustodial parent of the child(ren) named in this Petition. Respondent has not [ ] _____________________(date) [ ] child's birth or provided support since: [ ] A modification is appropriate due to a change in circumstances [ ] [ ] Existence of valid multiple orders Grounds for other remedy sought: Uniform Support Petition OMB 0970 - 0085 Expiration Date: 01/31/2008 Page 1 of 2 American LegalNet, Inc. www.USCourtForms.com UNIFORM SUPPORT PETITION, PAGE 2 Initiating IV-D Case No. III. Additional Supporting Information The following documents are attached to, and incorporated in, this Petition. These documents contain the required additional information. [ ] [ ] [ ] Petitioner's General Testimony Acknowledgment of Paternity [ ] [ ] Affidavit in Support of Establishing Paternity Birth Certificate of the Child Other: IV. Verification [ ] Under penalty of perjury, all information and facts stated in this Petition are true to the best of my knowledge and belief. Date Sworn to and Signed Before Me This Date, County/State [ ] Signature of Petitioner [ ] IV-D Representative/Title Notary Public, Court/Agency Official and Title Commission Expires Date Uniform Support Petition Signature of Petitioner's Attorney / Bar Number (if applicable) Page 2 of 2 American LegalNet, Inc. www.USCourtForms.com INSTRUCTIONS FOR UNIFORM SUPPORT PETITION PURPOSE OF THE FORM: The Uniform Support Petition is a legal pleading needed for the responding State to initiate action. Its purposes are to show how the tribunal has jurisdiction, to show enough facts to notify the respondent of the claim being made, and to provide the petitioner with a means to request specific action or relief. Additional information can be provided in the accompanying affidavits and other attachments. HEADING/CAPTION: Identify the Petitioner and Respondent names in the appropriate spaces. Check the appropriate space to identify the type of case: TANF; IV-E Foster Care, Medicaid only; former assistance, never assistance, or Non-IV-D. TANF means the obligee's family receives IV-A cash payments. A Medicaid only case is a case where the obligee's family receives Medicaid but does not receive TANF (IV-A cash payments). Under "Responding IV-D Case No." and "Responding Tribunal No.", enter appropriate case and tribunal numbers that the responding State uses to identify the case, if applicable and if known. Under “IV-D case number”, enter the number/identifier identical to the one submitted on the Federal Case Registry, which is a left-justified 15-character alphanumeric field, allowing all characters except asterisk and backslash, and with all characters in uppercase. Under "tribunal number", you may enter the docket number, cause number, or any other appropriate reference number. Under "Initiating IV-D Case No." and "Initiating Tribunal No.", enter appropriate case and tribunal numbers which your IV-D agency or local tribunal has assigned to the case. Under “IV-D case number”, enter the number/identifier identical to the one submitted on the Federal Case Registry, which is a left-justified 15-character alphanumeric field, allowing all characters except asterisk and backslash, and with all characters in uppercase. Under "tribunal number", you may enter the docket number, cause number, or any other appropriate reference number. SECTION I, ACTION: List the children on whose behalf the action in the petition is requested. Include each child's full legal name (First, Middle, Last), date of birth, and Social Security Number. Check the appropriate boxes to indicate which actions are requested. Multiple actions may be requested, as appropriate. Check "Establishment of Paternity" to request that paternity be established. In a IV-D case, ask another State to establish paternity only if use of long-arm jurisdiction is not available or appropriate. Be sure to attach an "Affidavit in Support of Establishing Paternity" for each child whose paternity is at issue. Check "Establishment of Order for" to request that an order be established. Indicate the type of order by checking the appropriate box. Check "Current Child Support, Including Medical Support" to request the establishment of a new child support order. If an order governing the same obligor, obligee, and child(ren) already exists, you should generally request the establishment of a new order only if: (1) there is more than one existing order, (2) the obligor, obligee, and child have all moved out of the issuing State, and (3) the parties have not filed written consent allowing an issuing State to assert jurisdiction. Uniform Support Petition Page 1 of 3 American LegalNet, Inc. www.USCourtForms.com Check "Retroactive Child Support" if seeking support for a prior period. States may establish child support awards covering a prior period, but such awards must be based on guidelines and take into consideration either the current earnings and income at the time the order is set, or the obligor's earnings and income during the prior period. The award of back support is not required under Federal rules, but may be appropriate in accordance with State law. Not all States have authority to establish support orders for prior periods. The law of the order State governs the extent to which retroactive support is available. A medical support provision must be included in any new or modified order in a IV-D case. Check "Medical Support Only" in a Medicaid case where a child support order does not exist and is not sought. If seeking to add medical support to an existing child support order, check the box for "Modification of a Support Order." Check "Spousal Support" to request establishment of a spousal support order. Do not check this item in a IV-D case; establishment of spousal support is not a IV-D function. When requesting establishment of spousal support, contact the support enforcement agency for the appropriate procedure. Check "Costs and Fees" to request an order for costs, such as costs of the delivery of the child and other medical costs not covered by insurance, or any fees. Provide testimony regarding the type and amount of these costs or fees. Check "Modification of a Support Order" to request modification of an existing order. If you are requesting modification of an order that was issued by the responding State, in most instances you do not need to complete a Uniform Support Petition. On the other hand, if you are requesting modification of an order that was issued by a State other than the responding State, a Uniform Support Petition is usually necessary. If multiple orders exist, do not ask the responding State to modify an order unless that order is the "controlling order" that has priority under UIFSA. UIFSA contains rules for determining which order is recognized when multiple orders exist. Check “Determination of Controlling Order and Arrears Reconciliation" if you are requesting this action. Check "Other Remedy Sought" if you are requesting an action not listed in section I. Specify in the space provided what remedy you are requesting. SECTION II, GROUNDS FOR REMEDY SOUGHT: In those cases where the respondent is the noncustodial parent of the children named in the petition, check the first box in section II of the petition. If appropriate, indicate when support payments stopped by checking “child’s birth” or by checking the second box and providing a date. Grounds (reasons) for remedy sought are required in actions to register an out-of-state child support order for modification. If you are using the petition to request a modification, check the second box under section II of the petition. Check “Existence of valid multiple orders” as grounds if a tribunal determination of controlling order or a reconciliation of arrears is sought. Grounds for remedy sought are also required when seeking a remedy that must be affirmatively sought under the responding State's law. Uniform Support Petition Page 2 of 3 American LegalNet, Inc. www.USCourtForms.com SECTION III, ADDITIONAL SUPPORTING INFORMATION: Check the appropriate boxes to indicate which documents are being sent with the petition. If you are sending forms with the petition that are not specifically identified in this section, mark the "Other" box and list the additional forms in the space provided. SECTION IV, VERIFICATION: The petition must be verified by the petitioner. Check the box under this part and have the petitioner (obligee, guardian, putative father, or authorized IV-D representative) sign and date the form. The petitioner's signature always requires a notary whether or not the petitioner is represented by an attorney. UIFSA allows a party to retain independent counsel. If the petitioner is represented by a private attorney, obtain the attorney's signature and Bar Number (if applicable) in the space provided in this part. ******************************************* The Paperwork Reduction Act of 1995 This information collection is conducted in accordance with 42 U.S.C. 651 et seq. and 45 CFR 303.7 of the child support enforcement program. Standard forms are designed to provide uniformity and standardization for interstate case processing. Public reporting burden for this collection of information is estimated to r average under half an hour per response. The responses to this collection are mandatory in accordance with the above statute and regulation. This information is subject to State and Federal confidentiality requirements; however, the information will be filed with the tribunal and/or agency in the responding State and may, depending on State law, be disclosed to other parties. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Uniform Support Petition Page 3 of 3 American LegalNet, Inc. www.USCourtForms.com