IN THE FAMILY COURT OF ________________ COUNTY, WEST VIRGINIA. In Re: The Marriage / Children of: Civil Action No. ____________ _________________________, and _________________________. Petitioner Respondent _________________________ _________________________ _________________________ _________________________ Address Address ________________ ________________ Daytime phone Daytime phone PETITION FOR MODIFICATION 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 / children is: __________________ ______________________________________________________________________. b. The Petitioner requests that the Order entered on the date of ________________________ be modified with regard to: ___ Parenting Plan ___ Child support ___ Spousal support ___ Other; (Explain) _________________________________________________________ __________________________________________________________________. = 2.I want the Court to modify the Order in these ways: (Check all that apply.) ___ Increase child support ___ Decrease child support ___ End child support ___ Change Parenting Plan with regard to: ___ Decision making; ___ Time spent with the children; ___ Other; (Explain) ________________________ __________________________________________________________________. ___ Order child support paid to another person, who SCA-FC-201 (12/01) Petition for Modification Page 1 of 3>>>> 2is:_____________________________. ___ Order child support paid by another person, who is:_____________________________. ___ Increase spousal support ___ Decrease spousal support___ End spousal support ___ Other modification request(s); (Explain.) _______________________________________ _______________________________________________________________________ ______________________________________________________________________. = 3.Circumstances that justify the modification I am requesting. (Explain all of the changes in circumstances you think justify the modifications you requested.) : ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________. 4.Information concerning Public Assistance and Child Support Enforcement Services a. ___ A Public Assistance check from Health and Human Services is now being received by: ___ The Children; ___ The Petitioner; ___ The Respondent. b. ___ A Public Assistance check from Health and Human Services was received in the past by: ___ The Children; ___ The Petitioner; ___ The Respondent. c. ___ Services from the Bureau for Child Support Enforcement have been applied for by: ___ The Petitioner; ___ The Respondent. d. ___ Income withholding services are currently being received from the Bureau for Child Support Enforcement. _________________________________ ___________________ Petitioners Signature Date You must sign the Verification on the next page before a Notary Public. VERIFICATION I, ____________________________, after making an oath or affirmation to tell the truth, say that the facts I have stated in this Petition are true of my personal knowledge; and if I have set forth matters upon information given to me by others, I believe that information to be true. SCA-FC-201 (12/01) Petition for Modification Page 2 of 3>>>> 3___________________________ ___________________ Signature Date This Verification was sworn to or affirmed before me on the ____ day of __________________, 2_____. _________________________ Notary Public / Other official My commission expires:______________________. CERTIFICATE OF SERVICE State of West Virginia County of _______________________________ I, ____________________________, the Petitioner for Modification, mailed my Petition by first class United States Mail, postage paid, to: ______________________________________________________________________________ (Name and Address) ________________________________ (Date mailed) And: ______________________________________________________________________________ (Name and Address) ________________________________ (Date mailed) ___________________________ ____________ Petitioners Signature Date SCA-FC-201 (12/01) Petition for Modification Page 3 of 3