THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) EXCEPTION AFFIDAVIT ON THE CHILD IMPACT PROGRAM ATTENDANCE Pursuant to RSA 458-D:8 I, I am currently incarcerated at or I previously attended the seminar on and court (case number, if known: ). Or, (date/year) in the matter of filed in , hereby certify that: The office of child support enforcement services has brought an action to enforce or modify an existing order in my case. Date Signature I certify that on this date I provided a copy of this document to (other party) or to (other party's attorney) by: Hand-delivery OR US Mail OR E-mail (E-mail only by prior agreement of the parties based on Circuit Court Administrative Order). Signature Date State of This instrument was acknowledged before me on My Commission Expires Affix Seal, if any , County of by Signature of Notarial Officer / Title ORDER Attendance at the seminar shall be waived pursuant to RSA 458-D:8. Other: Recommended: Date Signature of Marital Master Printed Name of Marital Master So Ordered: I hereby certify that I have read the recommendation(s) and agree that, to the extent the marital master/judicial referee/hearing officer has made factual findings, she/he has applied the correct legal standard to the facts determined by the marital master/judicial referee/hearing officer. Date Signature of Judge Printed Name of Judge NHJB-2621-F (03/25/2013) Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com