______________________________________ UNIFORM SUPPORT PETITION ___________ Petitioner IV-D Non Public Assistance IV-D Non PA Medicaid Full Services Respondent Medical Services Only IV-D Public Assistance IV-E Foster Care (IV-D Case) File Stamp Non-IV-D Responding IV-D Case No. Initiating IV-D Case No. Responding Docket No. Initiating Docket 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 children Full Name (First, Middle, Last) Date of Birth Social Security No. The Petitioner files this Petition to request: Establishment of a Paternity Establishment of Order for: Child Support Medical Coverage Spousal Support Reasonable Attorney Fees, Other Fees and Costs Support for a Prior Period; From: To: Paternity 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) American LegalNet, Inc. www.FormsWorkflow.com Respondent is the noncustodial parent of the children named in this Petition. A modification is appropriate due to a change in circumstances. Grounds for other remedy sought: Uniform Support Petition Page 1 of 4 FSA-201 (Rev. 9-97) Previous edition may be used. OMB No. 0970-0085 American LegalNet, Inc. www.FormsWorkflow.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 Affidavit in Support of Establishing Paternity Acknowledgment of Paternity Birth Certificate of the Child Other: IV. Verification Under penalties 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 Notary Public, Court/Agency Official and Title Commission Expires Date Uniform Support Petition Page 2 of 4 FSA-201 (Rev. 9-97) Previous edition may be used. Signature of Petitioner’s Attorney / Bar Number (if applicable) OMB No. 0970-0085 American LegalNet, Inc. www.FormsWorkflow.com