IN THE FAMILY CO URT OF ________________ CO UN TY, W EST VIR GIN IA Civil Action No. ____________ _____________________. Respondent _____________________ __________________________________________, Address Petiti oner _____________________________________ Daytime phone _____________________ and * Address _____________________.________________ Respondent Daytime phone _____________________ _____________________ Address ________________ Daytime phone PETITI ON FOR SUPPORT and / or ALLOCATION OF CUSTODIAL RESPONSI BILI TY1. a. The Petitioner is: ________________________________________. (Print your name.) b. The Petitioner currently resides in _____________________ County, West Virginia. c. List the full names, dates of birth, and social security numbers for the children for whom support and / or custodial responsibility is being requested. In the rest of the Petition, the children will always mean the children whose names you have listed here. SCA -FC-26 1 (12/01) Petition for Support & Allocation of Custodial Responsibility Page 1 of 7>>>> 2 Name Date of Birth Social Security Number ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ d. What is the Petitioners relationship to the children? ________________________________.e. What is the Petitioners relationship to the Respondent(s) listed above? __________________________________________________________________________ f. What is the Childrens relationship to the Respondent(s) listed above? __________________________________________________________________________ g. The first Respondent listed above currently resides: ___ at an address unknown to the Petitioner. ___ in _____________________ County, West Virginia. ___ outside the state of West Virginia, where the last known address was ______________ _____________________________________________________________________.h. The second Respondent listed above currently resides: ___ at an address unknown to the Petitioner. ___ in _____________________ County, West Virginia. ___ outside the state of West Virginia, where the last known address was ______________ _____________________________________________________________________.i. The parents of the children last cohabited together in _____________________ County, in the state of ___________________________, on the date of _______________________. ___ Do not know. j. Are the parents of the children currently expecting another child? ___ Do not know. ___ No ___ Yes If yes, what is the due date? __________________ k. The children currently reside with: ___ Mother, at this address: _____________________ ______________________________________. ___ Father, at this address: ___________SCA -FC-26 1 (12/01) Petition for Support & Allocation of Custodial Responsibility Page 2 of 7>>>> 3 _____________________________________________. ___ The Petitioner, at this address: _____________________________________________________. ___ Someone else, whose name, relationship to the children, and address are: _______________________ __________________________________________________________________________. l. During the last five years, if any of the children have lived at addresses other than the address you just listed, list those other addresses below, and list the name and relationship to the children of all adults other than the parents who lived at these addresses with the children. If there is not enough room in the following space, use an additional sheet of paper. I have attached ____ additional sheet(s). ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 2. Check all of the following items that apply. a. Has the Petitioner been a party or witness in any other proceeding, in any state, concerning the allocation of custodial responsibility for the children? ___ Yes ___ No b. Is the Petitioner aware of any other proceeding, past or present, in any state, concerning allocation of custodial responsibility for the children? ___ Yes ___ No c. Is the Petitioner aware of any other person, other than the parties to this case, who has physical custody of, or claims any custodial right concerning the children? ___ Yes ___ No 3. Check all of the following items that apply. a. ___ The children have resided in West Virginia for at least 6 months preceding the filing of this case, or from birth, if less than six months old. b. ___ The Petitioner believes it is in the best interest of the children for a West Virginia courtSCA -FC-26 1 (12/01) Petition for Support & Allocation of Custodial Responsibility Page 3 of 7>>>> 4 to assume jurisdiction of this case, because one or both of the parents have a significant connection to West Virginia, and West Virginia is the location of a substantial number of witnesses and / or other sources of evidence relating to the childrens current or future care and personal relationships. c. ___ The children are now present in West Virginia, and have been abandoned here.d. ___ The children are now present in West Virginia, and the Petitioner believes it is necessary for a West Virginia court to assume jurisdiction of this case on an emergency basis to protect the children, because the children have been subjected to or threatened with mistreatment or abuse, or have otherwise been neglected, or are depending on persons other than their parents.e. ___ The Petitioner believes no other state has jurisdiction over this case, and it would be in the childrens best interest for a West Virginia court to assume jurisdiction.f. ___ Another state has declined to assume jurisdiction over this case on the ground West Virginia is the more appropriate place to decide matters relating to the allocation of custodial responsibility, and for this reaso