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Registration Statement Form. This is a Virginia form and can be use in District Court Statewide.
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Tags: Registration Statement, OMB-085I, Virginia Statewide, District Court
REGISTRATION STATEMENT
Responding IV-D Case Number
Responding Tribunal Number
Initiating IV-D Case Number
Initiating Tribunal Number
Action:
[
] Register for Enforcement
[
] Register for Modification
I. Case Summary (Background of this Matter: Court / Administrative Actions)
Date of Support Order
State and County Issuing Order
Support Amount/Frequency
$
Date of Last Payment
[
] Tribunal Has Determined This to Be Controlling Order
II. Mother Information
Full Name
(first, middle, last)
[
Tribunal Case Number
Amount of Arrears
$
[
Period of Computation
________________ thru ______________
Date
Date
] Only Order
] Obligor
[ ] Obligee
Address (Street, City, State, Zip)
Employer (Name, Street, City, State, Zip)
] Obligor
[ ] Obligee
Address (Street, City, State, Zip)
Employer (Name, Street, City, State, Zip)
Aliases, Maiden Name
Social Security Number:
III. Father Information
Full Name
(first, middle, last)
[
Aliases
Social Security Number:
IV. Caretaker (If Not a Parent)
Full Name
(first, middle, last)
Relationship to Child(ren) _________________________ [
Address (Street, City, State, Zip)
] Has legal custody/guardianship of child(ren)
Aliases
Social Security Number:
V. Additional Case Information
[ ] Nondisclosure Finding Attached
This order is registered in the following states:
Description and location of any property not exempt from execution:
Other:
VI. Verification / Certification
Under penalties of perjury, all information and facts concerning the arrearage accrued under this order are true to the best of my
knowledge and belief.
__________________________________
Date
__________________________________
Sworn to and Signed Before Me This
Date, County/State
Registration Statement
_____________________________________________________________________________
[ ] Party Seeking Registration
[ ] Records Custodian
___________________________________________
Notary Public, Court/Agency Official and Title
__________________________
______
Commission Expires
OMB 0970 - 0085 Expiration Date: 01/31/2011
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