UNIFORM SUPPORT PETITION Petitioner IV-D Case: Respondent Non-IV-D Case: [ [ [ [ [ [ FL-500 ] TANF ] IV-E Foster Care ] Medicaid Only ] Former Assistance ] Never Assistance ] Responding IV-D Case No. __________________________________ Responding Tribunal No. _____________________________________ File Stamp Initiating IV-D Case 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): Date of Birth Social Security No. Full Name (First, Middle, Last) The Petitioner files this Petition to request: [ ] Establishment of Paternity [ ] Establishment of Order for: [ ] Child Support [ ] Medical Coverage [ ] Spousal Support [ ] Reasonable Attorney Fees, Other Fees and Costs To: [ ] Support for a Prior Period; From: [ ] Genetic Testing Costs in the Amount of $ _______________________ [ ] Modification of a Support Order [ ] 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. A modification is appropriate due to a change in circumstances. Grounds for other remedy sought: Uniform Support Petition OMB 0970 - 0085 American LegalNet, Inc. www.USCourtForms.com Page 1 of 2 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 [ ] Other: [ ] Affidavit in Support of Establishing Paternity [ ] Birth Certificate of the Child 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 _________________________________________________________________________ [ ] Signature of Petitioner [ ] IV-D Representative/Title _______________________________ ___________________________________________________________________ Sworn to and Signed Before Notary Public, Court/Agency Official and Title Me This Date, County/State ______________________________________ Commission Expires _________________________ Date Uniform Support Petition ________________________________________________________________________ Signature of Petitioner's Attorney / Bar Number (if applicable) American LegalNet, Inc. www.USCourtForms.com Page 2 of 2 FL-500/OMB 0970 - 0085 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 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 "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 "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 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 appropriate. Be sure to attach an "Affidavit in Support of Establishing Paternity" for each child whose paternity is at issue. # Check "Establishment of Order" to request that an order be established. Indicate the type of order by checking the appropriate box. Check "Child Support" to request the initial 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. 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 Instructions for Uniform Support Petition--Page 1 American LegalNet, Inc. www.USCourtForms.com function. When requesting establishment of spousal support, contact the support enforcement agency for the appropriate procedure. Check "Support for a Prior Period" to request establishment of support for a prior period. On the "From" and "To" lines, enter the beginning and ending dates of the prior period. If support for multiple prior time periods is being requested, enter the beginning date of the first period in the "From" line, and enter the closing date of the last time period in the "To" line. 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. Check "Genetic Testing Costs" to request an order for reimbursement of costs incurred as a result of genetic testing for paternity establishment purposes. If the initiating State has already incurred costs for genetic testing, enter the amount of the costs on the blank line. If reimbursement of previously paid genetic tests is not sought, but genetic tests may be ordered, enter "actual" on the blank line. Check "Medical Coverage" to request establishment of an order that provides for the provision of medical insurance or other health care coverage. A medical support provision must be included in any new or modified order in a IV-D case. Check "Reasonable Attorney Fees, Other Fees and Costs" to request an order for attorney fees or other costs such as costs of the delivery of the child and other medical costs not covered by insurance. Provide testimony regarding the type and amount of these costs. # 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 "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. # 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. Instructions for Uniform Support Petition--Page 2 American LegalNet, Inc. www.USCourtForms.com # Grounds for remedy sought are also required when seeking a remedy that must be affirmatively sought under the responding State's law. 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 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 average one hour per response. The responses to this collection are mandatory in accordance with 45 CFR 303.7. 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. Instructions for Uniform Support Petition--Page 3 American LegalNet, Inc. www.USCourtForms.com