Registration Statement Form. This is a Virginia form and can be use in District Court Statewide.
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 Page 1 of 1 American LegalNet, Inc. www.FormsWorkflow.com