GENERAL TESTIMONY Petitioner: Name (first, middle, last) Social Security Number IV-D Case: [ [ [ [ [ ] ] ] ] ] TANF IV-E Foster Care Medicaid Only Former Assistance Never Assistance Respondent: Name (first, middle, last) Social Security Number File Stamp Non-IV-D Case: [] Responding IV-D Case Identifier Responding Tribunal Number Initiating IV-D Case Identifier Initiating Tribunal Number Petitioner is: [] [] Respondent is: [] [] Obligee Obligor Obligee Obligor [] [] [] [] Caretaker Other than Parent Foster Care Caretaker Other than Parent 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 [ ] See Section X 2. [ ] Nondisclosure Finding Attached 3. Full Name (first, middle, last) Nickname, alias, maiden name, former married name, etc. 4. Home Address [ ] Confirmed _____________ (date) 5. Social Security Number 7. Home Phone ( ) 6. Date of Birth 8. Work Phone () 9. Employer Name & Address [ ] Confirmed ________(date) 10 (a). Occupation, Trade or Profession 10 (b). Highest level of Education Attained 11. Estimated Gross Monthly Earnings $ 13. Real or Personal Property (type and location) 12. Other Monthly Income (& source) $ B. Physical Description of Child (ren)'s Mother (Attach photo if available.) 1. Race C. 2. Height 3. Weight 4. Hair Color 5. Eye Color Present Martial Status of Child(ren)'s Mother 2. [ ] Single 5. [ ] Legally Separated 3. [ ] Living with Non-Marital Partner 6. [ ] Separated 7. [ ] Unknown Page 1 of 10 American LegalNet, Inc. www.FormsWorkFlow.com 1. [ ] Married 4. [ ] Divorced General Testimony OMB 0970-0085 Expiration Date: 05/31/2014 GENERAL TESTIMONY, PAGE 2 D. Information about Current Spouse of Partner of Child (ren)'s Mother 1. Name of Current Spouse or Partner (first, middle, last) Initiating IV-D Case Identifier 2. Is Current Spouse/Partner Employed? [ ] Yes [ ] No [ ] Unknown 3. Name and Address of Spouse's/Partner's Employer 4. Spouse's/Partner's Estimated Gross Monthly Earnings $ E. Is the children (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 d. Living With: f. Monthly Amount; Gross: Net: a. Full Name (first, middle, last) c. Relationship e. Source of Support/Income 2. a. Full Name (first, middle, last) c. Relationship e. Source of Support/Income d. Living With: b. Date of Birth f. Monthly Amount; Gross: Net: 3. a. Full Name (first, middle, last) c. Relationship e. Source of Support/Income d. Living With: b. Date of Birth f. Monthly Amount; Gross: Net: II. Personal Information About Child(ren)'s Father A.1. Father is: [ ] Obligee [ ] Obligor [ ] See Section X 2. [ ] Nondisclosure Finding Attached 3. Full Name (first, middle, last) Nickname, Alias 4. Home Address [ ] Confirmed _____________ (date) 5. Social Security Number 7. Home Phone ( ) 9. Employer Name & Address [ ] Confirmed ________(date) 6. Date of Birth 8. Work Phone ( ) 10 (a). Occupation, Trade or Profession 10 (b). Highest level of Education Attained 11. Estimated Gross Monthly Earnings $ 13. Real or Personal Property (type and location) 12. Other Monthly Income (& source) $ B. Physical Description of Child (ren)'s Father (Attach photo if available.) 1. Race 2. Height 3. Weight 4. Hair Color 5. Eye Color General Testimony Page 2 of 10 American LegalNet, Inc. www.FormsWorkFlow.com GENERAL TESTIMONY, PAGE 3 C. Present Martial Status of Child(ren)'s Father 2. [ ] Single 5. [ ] Legally Separated Initiating IV-D Case Identifier 1. [ ] Married 4. [ ] Divorced 3. [ ] Living with Non-Marital Partner 6. [ ] Separated 7. [ ] Unknown D. Information about Current Spouse of Partner of Child (ren)'s Father 1. Name of Current Spouse or Partner (first, middle, last) 2. Is Current Spouse/Partner Employed? [ ] 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 children (ren)'s father 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 d. Living With: f. Monthly Amount; Gross: Net: a. Full Name (first, middle, last) c. Relationship e. Source of Support/Income 2. a. Full Name (first, middle, last) c. Relationship e. Source of Support/Income d. Living With: b. Date of Birth f. Monthly Amount; Gross: Net: 3. a. Full Name (first, middle, last) c. Relationship e. Source of Support/Income d. Living With: b. Date of Birth f. Monthly Amount; Gross: Net: [ ] See Section X III. Personal Information About Caretaker Other than Parent 1. Caretaker's Relation to Child is: [ ] Has legal custody/guardianship of child 3. Full Name (first, middle, last) Nickname, alias, maiden name, former married name, etc. 4. Home Address [ ] Confirmed _____________ (date) 5. Social Security Number 8. Home Phone ( ) 10. Employer Name & Address [ ] Confirmed _______(date) 2. [ ] Nondisclosure Finding Attached 6. Date of Birth 7. Sex 9. Work Phone () 11 (a). Occupation, Trade or Profession 11 (b). Highest level of Education Attained 12. Estimated Gross Monthly Earnings $ 14. Date Child(ren) Began Residing With Caretaker 13. Other Monthly Income (& source) $ General Testimony Page 3 of 10 American LegalNet, Inc. www.FormsWorkFlow.com GENERAL TESTIMONY, PAGE 4 IV. Legal Relationship of Parents 1. 3. 4. 6. 7. 9. 11. [ ] Never married to each other 2. [ ] Married on Initiating IV-D Case Identifier [ ] See Section X in Date County/State [ ] Married by common law for the period Dates in County/State [ ] Separated on Date 5. [ ] Divorced on Date in County/State [ ] Legally separated on Date in County/State [ ] Divorce pending in County/State 8. [ ] Support Order Entered on Date [ ] No support order 10. [ ] Other Tribunal & Location (Divorce Legal Separation, Support Order): [ ] See Section X [ ] Nondisclosure Finding Attached V. Dependent Child(ren) in this Action A. List obligor's (named on page 1 of this form) child (ren) only. 1. a. Full Legal Name (first, middle, last) b. Address f. Paternity Established? [ ] Yes (check how) [ ] No [ ] By order [ ] By voluntary acknowledgment [ ] By adoption [ ] By conclusive marital presumption [ ] Other: g. Support Order Established? [ ] Yes [ ] No h. Living with Petitioner? [ ] Yes [ ] No f. Paternity Established? [ ] Yes (check how)