STATE OF MAINE DISTRICT COURT Location: Docket No.: Plaintiff v. Defendant COMPLAINT FOR DETERMINATION OF PARENTAGE, PARENTAL RIGHTS & RESPONSIBILITIES, CHILD SUPPORT M.R. Civ. P. 100-126 19-A M.R.S. �� 1831-1938, 1653, 2001-2012 Other Party (if any) 1. Plaintiff and Defendant, who are not married, are the parents of the following child(ren): Name Date of Birth Present Address 2. Plaintiff resides in (town) , (county) , (state) If either party wishes to keep his/her address confidential, that party may complete an Affidavit for Confidential Address (form FM-057). This form is available at the Clerk's Office. 3. Defendant resides in (town) , (county) , (state) 4. A. List below where and with whom the child(ren) have lived within the past 5 years. Name and present address of person child(ren) lived with Dates child(ren) lived with that person Town and State where child(ren) lived with that person 5. The court has jurisdiction because (check all boxes that apply): Defendant resided with the child(ren) in Maine. Defendant resided in Maine and provided prenatal expenses and support for the child(ren). Defendant engaged in intercourse in Maine and the child(ren) may have been conceived by that act of intercourse. The child(ren) reside in Maine as a result of the acts or directives of Defendant. Defendant consents to jurisdiction in Maine. Any other basis for personal jurisdiction in Maine. FM-006, Rev. 06/16 Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com 6. (Check one) Plaintiff is the child(ren)'s: Biological mother *A party filing as a de facto parent must Biological father file an additional affidavit. See Presumed parent instructions. 19-A M.R.S. � 1891(2). Acknowledged parent Adjudicated parent De facto parent* Intended parent Other (state the nature of parental relationship to the child(ren): ________________________. 7. (Check one) Defendant is the child(ren)'s: Biological mother Biological father Presumed parent Acknowledged parent Adjudicated parent Intended parent Other (state the nature of parental relationship to the child(ren): _________________________. Quick Reference Guide: An acknowledged father is a person who is the genetic father of the child and signed a valid acknowledgment of paternity with the intent to establish paternity. 19-A M.R.S. � 1861 An adjudicated parent is a person determined to be a parent of the child(ren) by a court order. A presumed parent is a person who was married to the other parent when the child was conceived or born; or a person that resided in the same household with the child and openly held out the child as that person's own from the time the child was born or adopted and for a period of at least 2 years thereafter and assumed personal, financial, or custodial responsibilities for the child. A biological parent is a person who is the genetic parent of the child. A de facto parent is a person who, pursuant to 19-A M.R.S. � 1891, is recognized as a parent of the child. A person seeking to be adjudicated a de facto parent of a child must complete and file an affidavit alleging under oath specific facts to support the existence of a de facto parent relationship with the child. An intended parent is a person married or unmarried, who manifests the intent to be legally bound as the parent of a child resulting from assisted reproduction or a gestational carrier agreement. In the case of a married couple, any reference to an intended parent includes both spouses. 8. Other possible parents (check one) The child(ren) do not have any other acknowledged, adjudicated, intended, or presumed parents. OR The child(ren) have an acknowledged, adjudicated, intended, or presumed parent. That parent's name is:__________________________. That parent's address is: _____________________________________. 9. Plaintiff has not been involved in any way in, and has no information about, another court case in any state concerning the custody of the child(ren) except as follows: Protection from Abuse (provide docket number):____________________________________________. Probate Matter (provide docket number):___________________________________________________ Other (describe what kind of other case and provide docket number): FM-006, Rev. 06/16 Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com 10. No one other than the parties has physical custody of the child(ren), or claims to have custody or visitation rights with respect to the child(ren), except as follows: 11. Name change of child(ren) (check one) I am not asking the court to change the child(ren)'s name(s). Order that the name(s) of the child(ren) be changed: A. The child's name is B. The child's name is C. The child's name is . I ask that the child's name be changed to . I ask that the child's name be changed to . I ask that the child's name be changed to . . . AND I assert that there is good cause for the court to change the child(ren)'s name(s) for the following reasons. 19-A M.R.S. � 1843(3):_____________________________________________________________________. 12. (Check all boxes that apply) No public assistance benefits have ever been received for the child(ren). OR Public assistance benefits have been, are now, or will be received for the child(ren). AND Plaintiff has sent a copy of this complaint to the Department of Health and Human Services at the following address: Support Enforcement Division, Central Office Supervisor, State House Station 11, Augusta, ME 04333-0011. (A copy must be sent when the child(ren) have been, are now or will be receiving public assistance benefits.) The Department of Health and Human Services has issued a child support order regarding the child(ren). (If such an order has issued, a copy of the order must be attached to this Complaint). The Department of Health and Human Services has been contacted to set up, review, change or enforce a child support order regarding the child(ren). PLAINTIFF REQUESTS that the court; (Check all boxes that apply) Order genetic testing pursuant to 19-A M.R.S. � 1911. Establish that the parties are the parents of the child(ren) listed in this complaint. Determine parental rights and responsibilities for the minor child(ren) pursuant to 19-A M.R.S. � 1653, including child support. Determine the amount of any past child support and order payment of the past support. Allocate reimbursement of birth expenses and medical expenses for the child(ren). Change the child(ren)'s names. Award reasonable attorney's fees. Date: (Plainti