UNIFORM SUPPORT PETITION Petitioner: Name (first, middle, last) Social Security Number Respondent: Name (first, middle, last) Social Security Number IV-D Case: [ [ [ [ [ ] TANF ] IV-E Foster Care ] Medicaid Only ] Former Assistance ] Never Assistance File Stamp Non-IV-D Case: [ ] Responding IV-D Case Number Responding Tribunal Number Initiating IV-D Case Number Initiating Tribunal Number 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 child(ren): Full Legal Name(first, middle, last) Date of Birth Social Security Number The Petitioner files this Petition to request (check all that apply): [ ] Establishment of Paternity [ ] Establishment of Order for: [ [ [ [ [ ] ] ] ] ] Current Child Support, Including Medical Support Retroactive Child Support Medical Support Only Spousal Support Costs and Fees [ ] Modification of a Support Order [ ] Determination of Controlling Order and Arrears Reconciliation [ ] Other Remedy Sought: II. Grounds Supporting the Remedy Sought in Section I (when applicable) [ ] Respondent is the non-custodial parent of the child(ren) named in this Petition. Respondent has not [ ] _____________________(date) [ ] child's birth or provided support since: [ ] A modification is appropriate due to a change in circumstances [ ] Existence of valid multiple orders [ ] Grounds for other remedy sought: Uniform Support Petition OMB 0970 - 0085 Expiration Date: 01/31/2011 Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com UNIFORM SUPPORT PETITION, PAGE 2 Initiating IV-D Case Number 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 penalty 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/Title Notary Public, Court/Agency Official and Title Commission Expires Date Uniform Support Petition Signature of Petitioner's Attorney / Bar Number (if applicable) Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com