IN THE FAMILY CO URT OF ________________ COUNTY, WEST VIR GINI A.In Re: The Marria ge / Children of: Civil Action No. ____________ _________________________, and _________________________. Petitioner Respondent _________________________ _________________________ _________________________ _________________________ Address Address ________________ ________________ Daytime phone Daytime phone PETITION FOR EXPEDITED MODI FICATION OF CHILD SUPPORT 1.GENERAL INFORMATION a. The Petitioner is: ________________________, who is: (Print your name.) ___ the mother / wife whose name is listed in the case style at the top of this page. ___ the father / husband whose name is listed in the case style at the top of this page. ___ other person, whose relationship to the Respondent and children is: ________________ ______________________________________________________________________. b. The Petitioner requests that the Order entered on the date of ________________________ be modified with regard to child support. The Petitioner wants child support: ___ Increased ___ Decreased 2.CHANGES IN PETITIONERS FINANCIAL CIRCUMSTANCES All changes must have occurred after the date of the Order you want modified. Income ___ Petitioners gross income has increased from $ ________ per month to $ ________ per month. ___ Petitioners gross income has decreased from $ ________ per month to $ ________ per month. ___ Petitioners gross income has not changed. If your income has changed, you must explain why it changed: ______________________ ___________________________________________________________________________ ___________________________________________________________________________ SCA -FC-22 6 (12/01) Petition for Expedited Modification of Child Supp ort Page 1 of 4>>>> 2 If you have pay stubs or other documents that show the change in your income, you should attach copies to this Petition. ___ I have not attached any documents. ___ I have attached documents, which are: ________________________________________ ___________________________________________________________________________ Child Care Costs ___ Petitioner pays child care costs to be able to work; and after the date of the Order Petitioner wants modified, those costs have: ___ increased from $ ________ per month to $ ________ per month; ___ decreased from $ ________ per month to $ ________ per month; ___ remained the same. Extraordinary Medical Expenses ___ Petitioner has incurred extraordinary medical expense after the date of the Order Petitioner wants modified. If you checked this item, you MUST list the amounts and dates for these expenses, and the reasons they were incurred. _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Other Changes In Financial Circumstances Explain in detail any other changes in your financial circumstances. Examples of such changes are: changes in the number of dependent children you support; cost of health insurance coverage; cost of housing. All changes must have occurred after the date of the Order you want modified. ______________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 3.CHANGES IN THE OTHER PARENTS FINANCIAL CIRCUMSTANCES All changes must have occurred after the date of the Order you want modified. Income ___ The other parents gross income has increased from $ ________ per month to $ ________ per month. ___ The other parents gross income has decreased from $ ________ per month to $ ________ per month. SCA -FC-22 6 (12/01) Petition for Expedited Modification of Child Supp ort Page 2 of 4>>>> 3 ___ The other parents gross income has not changed. If the other parents income has changed, explain why it changed: ______________________ ___________________________________________________________________________ ___________________________________________________________________________ If you have pay stubs or other documents that show the change in the other parents income, you should attach copies to this Petition. ___ I have not attached any documents. ___ I have attached documents, which are: _______________________________________________________________________ ___________________________________________________________________________ Child Care Costs ___ The other parent pays child care costs to be able to work; and after the date of the Order Petitioner wants modified, those costs have: ___ increased from $ ________ per month to $ ________ per month; ___ decreased from $ ________ per month to $ ________ per month; ___ remained the same. Extraordinary Medical Expenses ___ The other parent has incurred extraordinary medical expense after the date of the Order Petitioner wants modified. If you checked this item, you MUST list the amounts and dates for these expenses, and the reasons they were incurred. __________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Other Changes In Financial Circumstances Explain in detail any other changes in the other parents financial circumstances. Examples of such changes are: changes in the number of dependent children he / she supports; cost of health insurance coverage; cost of housing. All changes must have occurred after the date of the Order you want modified. _________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 4.CHILDREN SCA -FC-22 6 (12/01) Petition for Expedited Modification of Child Supp ort Page 3 of 4>>>> 4 List the name, date of birth