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Uniform Support Petition Form. This is a Virginia form and can be use in District Court Statewide.
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Tags: Uniform Support Petition, OMB-085D, Virginia Statewide, District Court
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
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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)
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