> Expiration Date: 01/31/2008
>
> INSTRUCTIONS FOR GENERAL TESTIMONY
>
> [PURPOSE OF THE FORM:]{.underline} The General Testimony provides a
> framework for stating the detailed information and evidence necessary
> to support the action requested in the petition. Its eleven sections
> may or may not apply to all cases. Before completing the form,
> carefully consider the status of the individual petitioner completing
> the testimony and his/her relationship to the respondent, the relief
> you plan to request in the petition, and other case characteristics to
> determine what information should be provided.
>
> (Note: all section headings contain a checkbox to be used when
> additional comments/remarks are desired or required. These
> comments/remarks should be placed in Section X.) As a general rule,
> requests for relief require completion of the following sections:
>
> Section No. Description Case Type Requiring Completion
>
> I Personal Information About Child(ren)\'s Mother All
>
> II Personal Information About Child(ren)\'s Father All
>
> III Personal Information About Cases where the caretaker is an
> individual
>
> Caretaker Other Than Parent other than the child(ren)\'s parent
>
> IV Legal Relationship of Parents All
>
> V Dependent Child(ren) in this Action All
>
> VI Medical Insurance All
>
> VII Support Order and Payment Information All cases where an order for
> support has
>
> been entered
>
> VII Obligor\'s Payment History All cases where an order for support
> has
>
> been entered; however, a certified copy of the court or agency payment
> history may be attached in lieu of Page 6a
>
> VIII TANF/Foster Care/Medical Assistance Status Cases where the
> obligee received TANF,
>
> Foster Care, or Medical Assistance benefits
>
> IX Financial Information Establishment and modification cases, as
>
> required by States\' guidelines
>
> X Other Pertinent Information When needed (Note: all section headings
>
> contain a checkbox to be used when\
> additional comments/remarks are desired or required.)
>
> XI Verification All
>
> [HEADING/CAPTION:]{.underline}
>
> Identify the petitioner and respondent in the appropriate spaces.
>
> Check the appropriate space to identify the type of case: IV-D TANF;
> IV-E Foster care, Medicaid only, former assistance, never assistance
> or Non-IV-D.
>
> [IV-D TANF]{.underline} means the obligee is receiving IV-A cash
> payments \[IV-A was formerly called Aid to Families with Dependent
> Children (AFDC) and is now called Temporary Assistance to Needy
> Families\]. In exchange for receiving benefits, a person receiving
> public assistance agrees to assign his/her support rights or to turn
> over to the State the right to child support payments paid by the
> obligated parent.
>
> General Testimony
>
> Page1 of 17
>
> [IV-E Foster Care]{.underline} means the child is in IV-E foster care
> and the case has been referred to the State/local child support agency
> to obtain support from the parents.
>
> [Medicaid Only]{.underline} means that the obligee is
> [not]{.underline} receiving public assistance (IV-A cash payments) but
> is receiving Medicaid. Medicaid is a federally-funded program that
> provides medical support for low income families. These cases can
> receive \"Full Services\" or \"Medical Services Only\".
>
> [Former Assistance]{.underline} means that the obligee received child
> support enforcement services while receiving IVA cash payments but is
> no longer receiving these payments.
>
> [Never Assistance]{.underline} means that the obligee applied for
> child support enforcement services but has not received public
> assistance (IV-A cash payments).
>
> [Non IV-D]{.underline} means the case is a private case that is
> [not]{.underline} being worked by the State or local child support
> enforcement or IV-D agency.
>
> Under \"Responding IV-D Case No.\" and \"Responding Tribunal No.\",
> enter appropriate case and tribunal numbers that the responding State
> uses to identify the case, if applicable and if known. Under "IV-D
> case number", enter the number/identifier identical to the one
> submitted on the Federal Case Registry, which is a left-justified
> 15-character alphanumeric field, allowing all characters except
> asterisk and backslash, and with all characters in uppercase. Under
> \"tribunal number\", you may enter the docket number, cause number, or
> any other appropriate reference number.
>
> Under \"Initiating IV-D Case No.\" and \"Initiating Tribunal No.\",
> enter appropriate case and tribunal numbers which your IV-D agency or
> local tribunal has assigned to the case. Under "IV-D case number",
> enter the number/identifier identical to the one submitted on the
> Federal Case Registry, which is a left-justified 15\
> character alphanumeric field, allowing all characters except asterisk
> and backslash, and with all characters in uppercase. Under \"tribunal
> number\", you may enter the docket number, cause number, or any other\
> appropriate reference number.
>
> Check the appropriate boxes to indicate whether the petitioner is the
> \"Obligee\", \"Obligor\", or \"Caretaker Other than Parent\", or
> whether this is a \"Foster Care\" case. Check the appropriate boxes
> for the\
> Respondent as well.
>
> [Obligee]{.underline} is the individual or State agency who is owed or
> is alleged to be owed support. If an obligee receives TANF benefits,
> s/he assigns certain support rights to the State.
>
> [Obligor]{.underline} is the individual who owes or is alleged to owe
> support. This term includes alleged or putative fathers whose
> paternity of the child(ren) has not yet been established.
>
> [Caretaker Other than Parent]{.underline} is an individual who is
> custodian of the child(ren) but who is [not]{.underline} the mother or
> father of the child(ren).
>
> [Foster Care]{.underline} indicates that the child is in foster care.
> In such cases, a State or political subdivision may seek support from
> both parents.
>
> In the name-block immediately above section I, fill in the name
> (First, Middle, Last) of the individual\
> providing the testimony and signing the form. In most cases this will
> be the individual obligee. However, it could also be an obligor
> seeking paternity establishment or modification of a support order, or
> an\
> authorized child support worker if the form is completed with
> information from the file. Note that verification by an individual
> petitioner is required for information personally known to him/her,
> and that testimony is given under penalty of perjury.
>
> [SECTION I, PERSONAL INFORMATION ABOUT CHILD(REN)\'S
> MOTHER:]{.underline} This section asks for information about the
> child(ren)\'s mother. If the mother is the respondent in this action,
> this information will
>
> General Testimony Page 2 of 17

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> be used to identify her, locate her, discover income and assets, begin
> the process of determining her ability to pay, and/or effect
> collection actions.
>
> If the individual completing this form is not the child(ren)\'s
> mother, the requested information may not be available. Provide as
> much information as possible.
>
> Part A
>
> Item 1: Indicate whether the child(ren)\'s mother is the \"Obligee\"
> or \"Obligor\".
>
> Item 2: Check this box if a nondisclosure finding pursuant to the
> Uniform Interstate Family Support Act (UIFSA) or an existing
> protective order excuses disclosure of the mother\'s address or other
> identifying information. Attach a copy of any nondisclosure finding.
> If a nondisclosure finding exists, do not enter the mother\'s
> address/identifying information on the form; you may enter a
> substitute address.
>
> Item 3: Enter the mother\'s full name (First, Middle, Last) on the
> first line and nickname, alias, maiden name, or former maiden name on
> the second line.
>
> Item 4: Enter the mother\'s home or residential address (Street, City,
> State, Zip Code). If this address has\
> been confirmed/verified by the initiating State agency, check the box
> indicating that the information has\
> been confirmed and the date it was confirmed. If the address cannot be
> confirmed, provide last known\
> address.
>
> Item 5: Enter the mother\'s Social Security Number.\
> Item 6: Enter the mother\'s date of birth (Month, Date, Year).\
> Item 7: Enter the mother\'s home phone number. Include the area code.
> Item 8: Enter the mother\'s work phone number. Include the area code
> and any extension.
>
> Item 9: Enter the name and address of the mother\'s employer. If this
> information has been\
> confirmed/verified by the initiating State agency, check the box
> indicating that the information has been confirmed and the date it was
> confirmed. If the employer name and address cannot be confirmed,
> provide last known information.
>
> Item 10(a): Enter the mother\'s occupation, trade, or profession.
>
> Item 10(b): Enter the mother\'s highest attained level of education.
> If the mother is the obligor, the educational level can be used by
> some responding States to impute the income of an unemployed or
> underemployed obligor.
>
> Item 11: Enter the dollar amount of the mother\'s estimated gross
> monthly earnings.
>
> Item 12: Enter the dollar amount of the mother\'s monthly income other
> than earnings. Indicate the source of the income.
>
> Item 13: List any real or personal property owned by the mother.
> Include type and location. Part B: Physical Description of
> Child(ren)\'s Mother
>
> Items 1 - 5: Provide a physical description of the mother by listing
> her race, height, weight, hair color, and eye color. This information
> may be helpful in locating or serving the mother if she is the
> respondent in this
>
> General Testimony Page 3 of 17
>
> action. Optional: attach a recent photo if available. A photo may be
> useful if the mother is the respondent and identification or service
> of process is necessary.
>
> When listing the mother\'s race, select from the following: 1) White
> (non-hispanic), 2) Black (non-hispanic), 3) Hispanic, 4) American
> Indian - Alaskan Native, or 5) Asian - Pacific Islander.
>
> Part C: Present Marital Status of Child(ren)\'s Mother
>
> Items 1 - 7: Check the appropriate box(es) which describe the
> mother\'s present marital status. This\
> information may be considered in determining the obligor\'s ability to
> pay or the obligee\'s need for support\
> when a support order is established or modified. Check \"single\" only
> if the mother has never been married\
> to anyone; if the mother has previously been married, check divorced,
> legally separated, or separated, as\
> appropriate.
>
> Part D: Information about Current Spouse or Partner of Child(ren)\'s
> Mother. Complete part D only if the mother currently has a spouse or
> non-marital partner. Otherwise, enter \"Not Applicable\".
>
> Item 1: Enter the name of the mother\'s current spouse or non-marital
> partner.
>
> Item 2: Check the appropriate box to indicate whether the mother\'s
> current spouse/partner is employed. Item 3: If the answer to item 2 is
> \"Yes\", enter the name and address of the spouse\'s/partner\'s
> employer. Item 4: Enter the spouse\'s/partner\'s estimated gross
> monthly earnings.
>
> Part E: Check the appropriate box to indicate whether the mother is
> responsible for dependents other than the child(ren) in this action
> (listed in Section V). If the answer is \"yes\", provide information
> about each dependent under items 1 through 3. If there are more than
> three dependents, provide information about the other dependents in
> Section X: Other Pertinent Information.
>
> Item a: Enter the full name of the dependent (First, Middle, Last).
> Item b: Enter the dependent\'s date of birth (Month, Date, Year). Item
> c: Enter the dependent\'s relation to the child(ren)\'s mother. Item
> d: Indicate who the dependent is living with.\
> Item e: Enter the dependent\'s source of support or income.
>
> Item f: Enter the monthly amount (both gross and net) of that support
> or income.
>
> [SECTION II, PERSONAL INFORMATON ABOUT CHILD(REN)\'S
> FATHER]{.underline} This section asks for\
> information about the child(ren)\'s father. This includes an alleged
> father if paternity has not yet been\
> established. If the father is the respondent in this action, this
> information will be used to identify him, locate him, discover income
> and assets, begin the process of determining his ability to pay,
> and/or effect\
> collection actions.
>
> If the individual completing this form is not the child(ren)\'s
> father, that individual may not be able to provide all of the
> requested information. Provide as much information as possible.
>
> General Testimony Page 4 of 17

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> Part A
>
> Item 1: Indicate whether the child(ren)\'s father is the \"Obligee\"
> or \"Obligor\".
>
> Item 2: Check this box if a nondisclosure finding pursuant to the
> Uniform Interstate Family Support Act (UIFSA) or an existing
> protective order excuses disclosure of the father\'s address or other
> identifying information. Attach a copy of any nondisclosure finding.
> If a nondisclosure finding exists, do not enter the father\'s
> address/identifying information on the form; you may enter a
> substitute address.
>
> Item 3: Enter the father\'s full name (Full, Middle, Last) on the
> first line and nickname or alias on the second line.
>
> Item 4: Enter the father\'s home or residential address (Street, City,
> State, Zip Code). If this address has\
> been confirmed/verified by the initiating State agency, check the box
> indicating that the information has\
> been confirmed and the date it was confirmed. If the address cannot be
> confirmed, provide last known\
> address.
>
> Item 5: Enter the father\'s Social Security Number.\
> Item 6: Enter the father\'s date of birth (Month, Date, Year).\
> Item 7: Enter the father\'s home phone number. Include the area code.\
> Item 8: Enter the father\'s work phone number. Include the area code
> and any extension.
>
> Item 9: Enter the name and address of the father\'s employer. If this
> information has been\
> confirmed/verified by the initiating State agency, check the box
> indicating that the information has been confirmed and the date it was
> confirmed. If the employer name and address cannot be confirmed,
> provide last known information.
>
> Item 10(a): Enter the father\'s occupation, trade, or profession.
>
> Item 10(b): Enter the father\'s highest attained level of education.
> If the father is the obligor, the educational level can be used by
> some responding States to impute the income of an unemployed or
> underemployed obligor.
>
> Item 11: Enter the dollar amount of the father\'s estimated gross
> monthly earnings.
>
> Item 12: Enter the dollar amount of the father\'s monthly income other
> than earnings. Indicate the source of the income.
>
> Item 13: List any real or personal property owned by the father.
> Include type and location. Part B: Physical Description of
> Child(ren)\'s Father
>
> Items 1 - 5: Provide a physical description of the father by listing
> his race, height, weight, hair color, and eye color. This information
> may be helpful in locating or serving the father, if he is the
> respondent in this action. You may attach a recent photo if available.
> A photo may be useful if the father is the respondent and
> identification or service of process is necessary.
>
> When listing the father\'s race, select from the following: 1) White
> (non-hispanic), 2) Black (non-hispanic), 3) Hispanic, 4) American
> Indian - Alaskan Native, or 5) Asian - Pacific Islander.
>
> General Testimony Page 5 of 17
>
> Part C: Present Marital Status of Child(ren)\'s Father
>
> Items 1 - 7: Check the appropriate box(es) which describe the
> father\'s present marital status. This information may be considered
> in determining the obligor\'s ability to pay or the obligee\'s need
> for support when a support order is established or modified.
>
> Part D: Information about Current Spouse or Partner of Child(ren)\'s
> Father. Complete part D only if the father currently has a spouse or
> non-marital partner. Otherwise, enter \"Not Applicable\".
>
> Item 1: Enter the name of the father\'s current spouse or non-marital
> partner.
>
> Item 2: Check the appropriate box to indicate whether the father\'s
> current spouse/partner is employed. Item 3: If the answer to item 2
> was \"Yes\", enter the name and address of the spouse\'s/partner\'s
> employer. Item 4: Enter the spouse\'s/partner\'s estimated gross
> monthly earnings.
>
> Part E: Check the appropriate box to indicate whether the father is
> responsible for dependents [other than]{.underline} the child(ren) in
> this action (listed in Section V). If the answer is \"yes\", provide
> information about each dependent under items 1 through 3. If there are
> more than three dependents, provide information about the other
> dependents in Section X: Other Pertinent Information.
>
> Item a: Enter the full name of the dependent (First, Middle, Last).
> Item b: Enter the dependent\'s date of birth.
>
> Item c: Enter the dependent\'s relation to the child(ren)\'s father.
> Item d: Indicate who the dependent is living with.\
> Item e: Enter the dependent\'s source of support or income.
>
> Item f: Enter the monthly amount (both gross and net) of that support
> or income.
>
> [SECTION III, PERSONAL INFORMATION ABOUT CARETAKER OTHER THAN
> PARENT:]{.underline} Complete this section only if the child(ren)\'s
> caretaker or custodian is not the child(ren)\'s mother or father.
>
> Item 1: Indicate the caretaker\'s relation to the child(ren). If the
> caretaker is a relative, indicate whether he/she is a maternal
> (mother\'s side of the family) or paternal (father\'s side of the
> family) relative. Examples include: \"maternal grandmother\" or
> \"paternal cousin\". Check the box if the caretaker has legal\
> custody/guardianship of the child(ren).
>
> Item 2: Check this box if a nondisclosure finding pursuant to the
> Uniform Interstate Family Support Act (UIFSA) or an existing
> protective order excuses disclosure of the caretaker\'s address or
> other identifying information. Attach a copy of any nondisclosure
> finding. If a nondisclosure finding exists, do not enter the
> caretaker\'s address/identifying information on the form; you may
> enter a substitute address.
>
> Item 3: Enter the caretaker\'s full name (First, Middle, Last) on the
> first line and nickname, alias, maiden name or former married name on
> the second line.
>
> Item 4: Enter the caretaker\'s home or residential address (Street,
> City, State, Zip Code). If this address\
> has been confirmed/verified by the initiating State agency, check the
> box indicating that the information has\
> been confirmed and the date it was confirmed. If the address cannot be
> confirmed, provide last known\
> address.
>
> General Testimony Page 6 of 17
>
> Item 5: Enter the caretaker\'s Social Security Number.\
> Item 6: Enter the caretaker\'s date of birth (Month, Date, Year).\
> Item 7: Enter the caretaker\'s sex or gender: male or female.\
> Item 8: Enter the caretaker\'s home phone number. Include the area
> code. Item 9: Enter the caretaker\'s work phone number. Include the
> area code and any extension.
>
> Note: If the caretaker does not have a legal obligation to contribute
> to the child(ren)\'s support, items 10 through 14 concerning the
> caretaker\'s employment and income may be privileged.
>
> Item 10: Enter the name and address of the caretaker\'s employer. If
> this information has been\
> confirmed/verified by the initiating State agency, check the box
> indicating that the information has been confirmed and the date it was
> confirmed. If the employer name and address cannot be confirmed,
> provide last known information.
>
> Item 11(a): Enter the caretaker\'s occupation, trade, or profession.
>
> Item 11(b): Enter the caretaker\'s highest attained level of
> education. If the caretaker is the obligor, the educational level can
> be used by some responding States to impute the income of an
> unemployed or underemployed obligor.
>
> Item 12: Enter the dollar amount of the caretaker\'s estimated gross
> monthly earnings.
>
> Item 13: Enter the dollar amount of the caretaker\'s monthly income
> other than earnings. Indicate the source of the income.
>
> Item 14: Enter the date the child(ren) began residing with the
> caretaker.
>
> [SECTION IV, LEGAL RELATIONSHIP OF PARENTS:]{.underline} Identify the
> legal relationship between the child(ren)\'s mother and father. Check
> all appropriate boxes and enter the pertinent corresponding
> information.
>
> Item 1: Check this box if the parents were never married to each
> other.
>
> Item 2: Check this box if the parents were married to each other.
> Indicate the date (Month, Date, Year) and County/State of the
> marriage.
>
> Item 3: Check this box if the parents were married by common law.
> Indicate the time period (dates) and the County/State of the common
> law marriage.
>
> Item 4: Check this box if the parents are separated. Indicate the date
> (Month, Date, Year) of the separation.
>
> Item 5: Check this box if the parents are divorced. Indicate the date
> (Month, Date, Year) and County/State of the finalized divorce.
>
> Item 6: Check this box if the parents are legally separated. Indicate
> the date (Month, Day, Year) and County/State of the legal separation.
>
> General Testimony Page 7 of 17
>
> Item 7: Check this box if divorce proceedings are pending. Indicate
> the County/State of the proceedings.
>
> Item 8: Check this box if a child support order has been entered.
> Indicate the date (Month, Date, Year) of the order.
>
> Item 9: Check this box if no child support order has been entered.
>
> Item 10: Check this box to indicate relationships not described by the
> options above. Describe the relationship on the line provided (e.g.
> mother and father lived together; mother and father had casual
> relationship; etc).
>
> Item 11: List the name and location of the tribunal (court or agency)
> that entered any divorce decree, legal separation, or child support
> order.
>
> Remember to attach the required number of copies of any existing
> support orders (including a divorce decree or separation agreement).
> You will generally need to attach a certified copy of any support
> order. Note, however, that some responding States may be able to take
> certain administrative enforcement actions without having a certified
> copy of the order, although a regular copy is still necessary.
>
> [SECTION V, DEPENDENT CHILD(REN) IN THIS ACTION:]{.underline} This
> information is used to identify child(ren) for whom paternity is to be
> established and/or for whom the establishment or enforcement of
> support or a modification thereof is sought.
>
> Part A: List all the children for whom paternity is to be established
> or support is sought or due from the obligor listed on page 1 of this
> form. These should be the same children listed in section I of the
> Uniform Support Petition. List only those children of the particular
> obligor named in this action. Provide information about each child
> under items 1 through 4. If there are more than four children, provide
> information about the other children in Section X: Other Pertinent
> Information. If a child listed is over 18, indicate whether (s)he is
> enrolled in high school or college; some responding States may require
> a letter from the child\'s\
> school for verification purposes.
>
> Attach a separate \"Affidavit in Support of Establishing Paternity\"
> for each child whose paternity is at issue.
>
> Check the box \"Nondisclosure Finding Attached\" if a nondisclosure
> finding pursuant to the Uniform Interstate Family Support Act (UIFSA)
> or an existing protective order excuses disclosure of the
> child(ren)\'s address or other identifying information. Attach a copy
> of any nondisclosure finding. If a nondisclosure finding exists, do
> not enter the child(ren)\'s address or identifying information on the
> form.
>
> Item a: Enter the child\'s full legal name (First, Middle, Last).
>
> Item b: Enter the child\'s address (Street, City, State, Zip Code).
> Item c: Enter the child\'s Social Security Number.\
> Item d: Enter the child\'s sex or gender: male or female. Item e:
> Enter the child\'s date of birth (Month, Date, Year).
>
> Item f: Check the appropriate box to indicate if the paternity of the
> child has been established or not. If \"yes\" is checked, check the
> appropriate box indicating how paternity was established, i.e., by
> order, voluntary acknowledgment, adoption, conclusive marital
> presumption, or other. If other is checked, explain on the line
> provided. Use Section X if more space is needed.
>
> General Testimony Page 8 of 17
>
> Item g: Check the appropriate box to indicate whether a child support
> order for the child has been established.
>
> Item h: Check the appropriate box to indicate whether the child is
> living with the petitioner. In this\
> instance, \"petitioner\" means the [individual]{.underline} who is the
> moving party rather than a State child support agency that is bringing
> action.
>
> Part B: Indicate the month and year when the child(ren) began residing
> in the State. If this information is not the same for all children,
> provide separate information for each child in Section X: Other
> Pertinent Information. If the child(ren) are older than six months of
> age and have resided in the State less than six months, provide
> information about the child(ren)\'s previous States of residence
> (including length of residence) in Section X: Other Pertinent
> Information. Information about the child(ren)\'s length of residence
> in the State is necessary under the Uniform Interstate Family Support
> Act (UIFSA) in order to determine which child support order should be
> prospectively enforced or modified if multiple orders exist.
>
> [SECTION VI, MEDICAL INSURANCE:]{.underline} This information is used
> to determine if medical coverage is\
> currently provided for the dependents. If coverage is not provided,
> additional information in this section is a basis for adding medical
> coverage to new and existing orders. You should provide this
> information in all IV-D cases.
>
> Item 1: Check the appropriate box to indicate whether the obligor is
> required by a child support order to provide medical insurance for the
> child(ren).
>
> Item 2: Check the appropriate box to indicate whether the obligor is
> required by a child support order to provide medical insurance for the
> obligee.
>
> Item 3: Check the appropriate boxes to indicate who provides medical
> coverage for the dependent child(ren) (listed in Section V) and
> obligee. The choices are: obligee, obligor, State Medicaid, obligee\'s
> employer, obligor\'s employer, and other. If you check \"other\",
> print the name of the person or entity that provides coverage (e.g.,
> obligee\'s current spouse). Check \"unknown\" if you do not know who
> provides coverage. Check \"no coverage\" if the child(ren)/obligee do
> not have coverage.
>
> In the appropriate spaces, enter the name and policy number of the
> obligee\'s insurance company, the obligor\'s insurance company, and
> any other relevant insurance company. If information about \"Other
> Insurance Company\" is provided, describe this company and its
> relation to the parties in Section X: Other Pertinent Information.
>
> Item 4: Enter the monthly medical insurance cost paid by the obligee
> for the obligor\'s child(ren) only. Do not include the portion of the
> monthly cost of medical insurance for the obligee or children other
> than the obligor\'s. If the obligee is the individual petitioner in
> this action and is seeking reimbursement for these medical insurance
> costs, attach proof of payment.
>
> Item 5: If medical insurance is provided by the obligee or the
> obligee\'s employer, do not answer this item; skip to item 6.
> Otherwise, enter the monthly cost to the obligee if he/she were to
> provide needed medical insurance. If the cost is unknown, enter
> \"unknown\". Some responding States may require you to enter a
> prorated amount per child.
>
> Item 6: As a lead for possible third party coverage, check the
> appropriate box to indicate whether the obligor\'s children were ever
> covered by medical insurance provided through the obligor or obligee
> or his/her current employer. If you check \"Yes\", describe this
> coverage in Section X: Other Pertinent\
> Information.
>
> General Testimony Page 9 of 17
>
> Item 7: Indicate whether any of the obligor\'s children have special
> needs or extraordinary medical\
> expenses not covered by insurance. This includes special medical
> needs, medical equipment, counseling, special schooling, etc. If yes,
> indicate the child involved, the type of need/expenses, and the
> related costs. Attach proof, such as a doctor\'s statement. If special
> needs are indicated, explain in detail any\
> agreements made to cover these costs including agreements that are
> verbal, written, or part of any court or administrative order.
>
> Item 8: Indicate whether the obligee is asking to be reimbursed for
> medical coverage by the obligor.
>
> [SECTION VII, SUPPORT ORDER AND PAYMENT INFORMATION:]{.underline} This
> information is used to justify the court or administratively ordered
> current support and arrearage obligation to be claimed in the
> petition.
>
> Item 1: Check the appropriate box to indicate whether a support order
> exists. If a support order does not exist, skip to Section VIII on
> page 7.
>
> Item 2: Check the appropriate box to indicate whether the child(ren)
> resided with the obligor at anytime during the period for which
> support is sought, except during periods of visitation specified by a
> tribunal\'s order. If \"yes\", identify period of residency with the
> obligor by entering dates (Month, Date, Year) in the spaces labelled
> \"From\" and \"Thru\". If this information is not the same for all
> children, provide separate information for each child in Section X:
> Other Pertinent Information.
>
> Item 3: Complete item 3 only if modification of a support order is
> requested; otherwise skip to item 4. Indicate the basis for requesting
> a modification by checking all appropriates boxes. If you check
> \"other\", explain in the blank and/or provide an explanation in
> Section X and check the "See Section X" checkbox next to the Heading
> on this page.)
>
> Item 4: Enter information on court or administratively ordered support
> amounts. Include information on the relevant original order,
> modifications, and interstate orders under the Uniform Reciprocal
> Enforcement of Support Act (URESA) or the Uniform Interstate Family
> Support Act (UIFSA). If there are more than three pertinent orders,
> describe the remaining orders in Section X: Other Pertinent
> Information.
>
> For each order, indicate:

-   Date of Order: the date the order was issued or entered.

-   Current Amount: the amount of periodic current support payments owed
    under the order. Specify the total amount for all children (listed
    in section V) even if the order designates a separate amount for
    each child.

-   Per Month/Week/Etc: the frequency with which current support must be
    paid (per month, per week,\
    etc).

-   Toward Arrears: the amount of any periodic payment ordered to go
    toward arrears. Specify the total\
    amount for all children (listed in section V) even if the order
    designates a separate amount for each\
    child.

-   Per Month/Week/Etc: the frequency with which the arrears payment
    must be paid.

-   Unpaid Interest: the amount of any unpaid interest due, and the date
    as of which the amount is correct.

> General Testimony Page 10 of 17

-   Total Arrears: the total amount of arrears owed under that order, if
    any. Specify the total amount for all children (listed in section V)
    even if the order designates a separate amount for each child. Enter
    the date as of which the amount is correct.

-   The name and address of the tribunal (court or agency) that entered
    the order.

> Remember to attach the required number of copies of all pertinent
> orders that relate to support. You will generally need to attach a
> certified copy of any support order. Note, however, that some
> responding States may be able to take certain administrative
> enforcement actions without having a certified copy of the order,
> although a regular copy is still necessary.
>
> Item 5: If the obligor owes reimbursement for prenatal, postnatal or
> general medical expenses paid by the obligee or State agency, indicate
> the total amount owed. Enter only the amount which the obligor has
> been ordered to pay. Enter the date as of which this amount is
> correct. Attach documentation.
>
> Item 6: Enter the amount of unpaid costs and fees owed by the obligor.
> Enter the date as of which the amount was correct. Describe the
> costs/fees on the blank line.
>
> Item 7: Check the appropriate box to indicate whether an affidavit
> from the obligee concerning direct payments is attached, or whether no
> direct payments were received by the obligee.
>
> Item 8: Check one of three options for supplying the obligor\'s
> support payment history:

-   Check the first box on the left to indicate that you will be
    providing a certified copy of your own court or agency\'s payment
    history (manual or computer generated) and skip to Section VIII on
    page 7. Provide any additional information (e.g., regarding
    interest, costs, fees) necessary to explain the payment history so
    that it can be correctly interpreted by the responding jurisdiction.

-   Check the middle box to indicate that you will be completing the
    payment history provided on page 6a of the General Testimony.

-   Check the last box on the right to indicate that you will not be
    providing a detailed arrears statement and skip to Section VIII on
    page 7. Note, however, to register an order under the Uniform
    Interstate Family Support Act (UIFSA), a sworn statement by the
    party seeking registration or a certified statement by the custodian
    of the records showing the amount of arrears is required.

> Fill in the spaces at the bottom of section VII on page 6. Under
> \"From (Year) to (Year)\" indicate the years covered by the obligor\'s
> support payment history. Also enter the name of the \"Agency which
> Prepared Audit/Payment History\".
>
> PAGE 6A: Complete this page if you checked the middle box in item 8,
> section VII, page 6. Enter the amount of [adjudicated]{.underline}
> arrears in the line at the top of the page; indicate the date of the
> order that established the arrears amount. Enter \"zero\" if there are
> no adjudicated arrears.
>
> The payment history tables on the rest of page 6a should show arrears
> that accrued since the date that arrears were adjudicated, or since
> the support order was entered if arrears have not been adjudicated.
> The beginning balance for the first year\'s table should be the amount
> of adjudicated arrears listed at the top of the page.
>
> At the bottom of the page, enter the total amount of adjudicated and
> accrued arrears; indicate the date that the amount is correct. If the
> amount of adjudicated arrears was used as the beginning balance in the
> first
>
> General Testimony Page 11 of 17
>
> year\'s payment history table, the ending balance in the last year\'s
> payment history table should equal the amount of adjudicated and
> accrued arrears that is entered at the bottom of the page.
>
> If continuation sheets are necessary, attach as needed. Each page of
> payment history should be certified or notarized according to the
> standard required by the State or local agency in preparing an
> interstate support pleading. The signature line can be signed either
> by a tribunal/agency representative or an individual, depending on
> State procedures. Some responding States may require a seal to be
> affixed if the records are provided by a tribunal or agency.
>
> [SECTION VIII, TANF/FOSTER CARE/MEDICAL ASSISTANCE
> STATUS:]{.underline} Complete this section only if:

-   You are seeking support for a prior period [and]{.underline}
    TANF/Foster Care benefits were paid, [or]{.underline}

-   You are seeking reimbursement for medical assistance costs.

> Otherwise, skip to section IX, Financial Information.
>
> Complete items 1 and 2 only if you are seeking support for a prior
> period (i.e., if you are seeking \"back support\" or support for a
> period prior to the establishment of an order). The award of support
> for a prior period is not required under Federal law but may be
> appropriate in accordance with State law. Not all States have
> authority to establish support orders for prior periods. However, the
> period of time the family received TANF benefits may be a relevant
> factor in setting an award for a prior period; this section provides
> space for this information.
>
> States may not, as a federally-reimbursable function, establish
> judgments solely for reimbursement of\
> public assistance, or pursue enforcement of such judgments established
> after March 22, 1993. States\
> must use guidelines as a rebuttable presumption, not the amount of
> unreimbursed public assistance, in\
> establishing orders after October 13, 1989. States may establish child
> support awards covering a prior\
> period, but such awards must be based on guidelines and take into
> consideration either the current\
> earnings and income at the time the order is set, or the obligor\'s
> earnings and income during the prior\
> period.
>
> Item 1: If known, specify the period of time when TANF/Foster Care
> benefits were paid to the obligee\'s family, and the State which
> provided the assistance and had an assignment of support rights. Only
> consider public assistance paid to the obligee or the children in this
> action (listed in section V).
>
> Item 2: If known, enter the total amount of TANF/Foster Care benefits
> paid, and the date as of which the amount was correct. Only include
> public assistance paid to the obligee or the children in this action
> (listed in section V).
>
> Item 3: Complete item 3 only if you are seeking reimbursement for
> medical assistance related to prenatal, postnatal or general expenses.
> Enter the dollar amount of medical expenses for which you are seeking
> reimbursement. Enter the name of the agency or person who paid the
> medical expenses and is due reimbursement. Attach appropriate proof or
> documentation, such as receipts.
>
> [SECTION IX, FINANCIAL INFORMATION:]{.underline} This section is used
> to obtain the petitioner's financial information needed to apply
> guidelines to determine the appropriate amount of support.
>
> Generally, you only need to complete this section if you are
> requesting establishment of an order or modification of an existing
> order, unless a responding State specifically asks for section IX to
> be completed to enforce an order. It is important to disclose all the
> information pertaining to income, expenses, and assets, as required by
> the responding State\'s guidelines. Failure to disclose information
> may seriously
>
> General Testimony Page 12 of 17
>
> affect the legal proceedings in the responding State and may
> unnecessarily delay the resolution of the support issue.
>
> However, before completing all parts of Section IX IV-D agencies may
> wish to consult the Interstate [Roster and Referral Guide]{.underline}
> or to contact the responding State to determine if all parts of
> Section IX are needed. Some responding States do not need all of the
> information in Section IX. IV-D agencies need to complete only those
> parts needed by the responding State.
>
> Part A: Monthly Income From All Sources
>
> Item 1: Check the appropriate box to indicate if the individual
> petitioner is employed. If \"yes\", list occupation. If \"no\", list
> income source.
>
> Item 2: List the gross monthly income of the individual petitioner,
> the petitioner\'s current spouse/partner (if applicable), and the
> obligor\'s dependents [who are in the petitioner\'s
> custody.]{.underline} If there are multiple\
> dependents in the petitioner\'s custody, combine the income from all
> the dependents and enter the total in the third column. List each
> income source separately under the categories provided in item 2. Be
> sure to provide information regarding all earnings and income sources,
> including salaries, wages, commissions, fees, bonuses, tips, and
> public assistance. You should consider seasonal or intermittent income
> on an annual basis (total for the year divided by 12).
>
> Item 2.a.: Enter the gross monthly amount of any public assistance
> received, including SSI, Family Assistance, and other. \"Family
> Assistance\" means IV-A cash payments \[IV-A was formerly called Aid
> to Families with Dependent Children (AFDC) and is now called Temporary
> Assistance to Needy Families\]. \"Other\" includes other types of cash
> public assistance.
>
> Item 2.b.: Enter the gross monthly amount of base pay salary or wages.
>
> Item 2.c.: Enter the gross monthly amount of overtime, commissions,
> tips, bonuses, parttime pay. Item 2.d.: Enter the gross monthly amount
> of unemployment compensation received.\
> Item 2.e.: Enter the gross monthly amount of worker\'s compensation
> received.\
> Item 2.f.: Enter the gross monthly amount of Social Security
> Disability received.\
> Item 2.g.: Enter the gross monthly amount of Social Security
> Retirement received.\
> Item 2.h.: Enter the gross monthly amount of dividends and interest
> received.\
> Item 2.i.: Enter the gross monthly amount of trust/annuity income
> received.\
> Item 2.j.: Enter the gross monthly amount of pension or retirement
> income received.\
> Item 2.k.: Enter the gross monthly amount of any child support
> payments received.\
> Item 2.l.: Enter the gross monthly amount of any spousal
> support/alimony received.
>
> Item 2.m.: Under \"All other sources\", be sure to include and
> describe monthly amounts for other income regularly received, such as
> self-employment income, regular in kind income, barter, or net income
> from rental property. If income is received on other than a monthly
> basis, annualize and divide by 12.
>
> General Testimony Page 13 of 17
>
> Item 3: Add all monthly income (lines 2a through 2m) and enter the
> total gross monthly income for the individual petitioner,
> petitioner\'s current spouse/partner (if applicable), and obligor\'s
> dependents who are in the petitioner\'s custody.
>
> Item 4: On the appropriate lines, list deductions from gross income
> including Federal, State, and local income tax withholding and Social
> Security tax (FICA) withholding. List deductions for each party (the
> individual petitioner, petitioner\'s current spouse/partner, and
> obligor\'s dependents who are in the\
> petitioner\'s custody).
>
> Item 5: Subtract the deductions (lines 4a through 4d) from the total
> gross monthly income (line 3) and enter the difference on line 5 under
> \"adjusted net monthly\" income for each party.
>
> Item 6: On the appropriate lines, enter other deductions for each
> party. Note that in some States these items are considered deductions
> while in other States they are considered expenses.
>
> Item 6.a.: \"Savings\" means amounts that are withheld or paid
> directly from a party\'s income and deposited in a savings account or
> fund.
>
> Item 6.b.: \"Loan repayment\" means amounts that are withheld or paid
> directly from a party\'s income to repay a loan.
>
> Item 6.c.: \"Mandatory Retirement\" means amounts [that are required
> by law]{.underline} to be withheld or paid directly from a party\'s
> income and deposited in a retirement account or fund. Enter amounts on
> this line only if the contributions are mandatory (i.e., required by
> law to be deducted).
>
> Item 6.d.: \"Non-mandatory Retirement\" means amounts that are
> [voluntarily]{.underline} withheld or paid directly from a party\'s
> income and deposited in a retirement account or fund. Enter amounts on
> this line only if the contributions are voluntary.
>
> Item 6.e.: \"Medical Insurance\" means medical insurance premiums
> withheld or paid from a party\'s income.
>
> Item 6.f.: \"Union dues\" means mandatory union dues that are withheld
> or paid directly from a party\'s income.
>
> Item 6.g.: \"Other\" includes all other deductions, such as State
> unemployment insurance tax and disability insurance premiums, where
> applicable; and certain employment-related expenses that are deducted
> directly from income.
>
> Item 7: Subtract the other deductions (lines 6a through 6g) from the
> adjusted net monthly income (line 5) and enter the difference on line
> 7 under \"net monthly income\" for each party.
>
> Item 8: Enter each party\'s gross income for the prior year.
>
> Attach the three most recent pay stubs from each current employer for
> all parties shown. Some responding States may require additional
> financial documentation as well; for example, the previous year\'s
> Federal and/or State income tax returns, W-2 forms, or Federal 1099
> forms.
>
> Part B: Monthly Expenses. On the appropriate lines, enter the monthly
> amount paid by the individual petitioner for the listed expenses.
> Generally, you should list expenses in the column labelled
> \"Petitioner\". However, if there are expenses that are directly
> attributable to a dependent of the obligor (e.g., uninsured
>
> General Testimony Page 14 of 17

![](media/image1.jpeg){width="8.5in" height="11.0in"}

> medical expenses for a child), list those expenses in the \"Obligor\'s
> Dependent(s)\" column. If you prorate\
> or divide expenses between the \"Petitioner\" and \"Obligor\'s
> Dependent(s)\" column, explain how you divided\
> the expenses. If there are multiple dependents in the petitioner\'s
> custody, combine the expenses for all\
> the dependents and enter the total. If an expense is paid on other
> than on a monthly basis, annualize and\
> divide by 12.
>
> Item 1: Enter the monthly amount paid for rent or mortgage.\
> Item 2: Enter the monthly amount paid for homeowner\'s or renter\'s
> insurance. Item 3: Enter the monthly amount paid for home maintenance
> and repairs.
>
> Item 4: Enter the monthly amount paid for heat.
>
> Item 5: Enter the monthly amount paid for electricity or gas. Item 6:
> Enter the monthly amount paid for telephone.
>
> Item 7: Enter the monthly amount paid for water/sewer.
>
> Item 8: Enter the monthly amount paid for food.
>
> Item 9: Enter the monthly amount paid for laundry, dry cleaning, and
> other cleaning. Item 10: Enter the monthly amount paid for clothing
> purchase.
>
> Item 11: Enter the monthly amount paid for life insurance.
>
> Item 12: Enter the monthly amount paid for medical insurance.
>
> Item 13: Enter the monthly amounts paid for special needs or
> extraordinary medical expenses not covered by insurance, and attach a
> description and documentation of the expenses and payments that are
> made (if not provided in adequate detail in Section VI on page 5 of
> the General Testimony).
>
> Item 14: Enter the monthly amount paid for other health related
> expenses not covered by insurance, including: doctors, dentists,
> medications and drug store items, and such expenses as glasses,
> hearing aids, etc.
>
> Item 15: Enter the monthly amount of auto payment.
>
> Item 16: Enter the monthly amount paid for auto insurance.
>
> Item 17: Enter the monthly amount paid for other auto expenses such as
> auto repairs or licenses.
>
> Item 18: Enter the monthly amount paid for other transportation
> expenses, such as public transportation, bus, or subway.
>
> Item 19: Specify the monthly amount paid for child care (work-related
> or otherwise), the provider, and the frequency child care is used
> (e.g., hours per week). Some responding States also require that you
> attach verification or proof of child care expenses, and some
> responding States need to know if the child care is work-related.
>
> General Testimony Page 15 of 17
>
> Item 20: Enter the monthly amount of any support payments actually
> made by the individual petitioner for child, spousal or family
> support.
>
> Item 21: Enter the monthly amount paid for internet service.
>
> Item 22: Under \"Other\", be sure to include and explain personal
> educational expenses; educational expenses for obligor\'s child(ren)
> including books, fees, supplies and tuition; garbage collection fees;
> cable television fees; contributions; dues; newspapers; entertainment;
> hobbies or sports.
>
> Total Monthly Expenses: At the end of part B, add the totals of line 1
> through line 22 and enter the total on the lines beside Total Monthly
> Expenses for both the individual petitioner and the obligor\'s
> dependents.
>
> Part C: Assets. This section lists assets owned by the individual
> petitioner.
>
> Item 1: Describe real estate owned by the individual petitioner by
> entering the address (including street, county, State and zip code),
> the owner(s) (including any co-owners other than the individual
> petitioner), and the title. In the appropriate spaces, enter the
> assessed value and the amount of any mortgage. Subtract the amount of
> the mortgage from the assessed value and enter the difference on the
> line on the right hand side of the page.
>
> Item 2: List any IRA, Keogh, pension, profit sharing, or other
> retirement plan. Include the institution or plan name and account
> number, and the amount of funds.
>
> Item 3: Enter the dollar amount under any tax deferred annuity plan.
> Item 4: Enter the present cash value of any life insurance policy.
>
> Item 5: List any savings account, checking account, money market
> account, certificate of deposit (CD). Include the institution name and
> account number and the amount of funds in the account. If additional
> space is needed, provide information in Section X.
>
> Item 6: Describe any automobiles or other vehicles owned by the
> individual petitioner by entering the make, model, and year. In the
> appropriate spaces, enter the estimated value of the vehicle and the
> dollar amount of any loan balance due on the vehicle. Subtract the
> loan balance from the estimated value and enter the difference on the
> line on the right hand side of the page.
>
> Item 7: Describe any other assets owned by the individual petitioner,
> such as personal property or securities. Enter the dollar value of the
> asset in the right hand column. If additional space is needed, provide
> information in Section X.
>
> Total Assets: Add all the dollar amounts in the right hand column (for
> items 1 through 7 in part C) and enter the total on the line by Total
> Assets.
>
> [SECTION X, OTHER PERTINENT INFORMATION:]{.underline} Use this section
> to provide additional information or explanations. If it is related to
> a previous section, identify the section, part, and item number as\
> appropriate.
>
> [SECTION XI, VERIFICATION:]{.underline} Attach the appropriate number
> of copies of any existing support order, and check the box indicating
> that the copies are attached. You will generally need to attach a
> certified copy of any support order. Note, however, that some
> responding States may be able to take certain administrative
> enforcement actions without having a [certified]{.underline} copy of
> the order, although a regular copy is still necessary. Some States may
> also need copies of custody or change in custody orders, if relevant.
>
> General Testimony Page 16 of 17
>
> Check the other boxes to indicate any other items that are attached,
> including: a copy of the certified child support payment records;
> copies of the three most recent pay stubs from the current employer;
> copies of bills for prenatal, postnatal, or general health care of
> mother and child; assignment or subrogation of\
> support rights; \"Affidavit in Support of Establishing Paternity\";
> copy of child(ren)\'s birth certificates; an acknowledgment of
> parentage; documentation of legal custody/guardianship of child(ren);
> documentation that child(ren) are in foster care; and any other
> attachments (such as copies of bills for parentage testing or the
> common law statute of the initiating State).
>
> [\"Affidavit in Support of Establishing Paternity\"]{.underline} is a
> standard interstate form completed by the moving party \[usually
> child(ren)\'s mother or alleged father\] who is seeking to establish
> the alleged father\'s paternity of the child(ren). The form provides
> evidence regarding the father\'s paternity. In interstate cases, a
> separate form must be completed for each child whose paternity is at
> issue.
>
> [Acknowledgment of Parentage]{.underline} is an affidavit or form
> signed by the alleged father (and usually the mother as well)
> voluntarily acknowledging the alleged father\'s paternity of the
> child(ren). These forms are used by hospital-based programs, State
> child support agencies, and other entities.
>
> If the individual petitioner is indigent and unable to pay the costs
> of these proceedings, check the "Other" checkbox and provide an
> explanation on the line provided. Note that checking this box does
> [not]{.underline} guarantee that the individual petitioner will be
> exempt from all costs and fees.
>
> The person(s) providing the testimony \-- the individual petitioner
> and/or agency representative \-- should sign and date the testimony at
> the bottom of page 10. Some States [require]{.underline} the
> individual petitioner\'s signature; check with the [Interstate Roster
> and Referral Guide]{.underline} or the responding State to determine
> the responding State\'s requirements. The form contains space for a
> notary to authenticate the signatures.
>
> [The Paperwork Reduction Act of 1995]{.underline}
>
> This information collection is conducted in accordance with 42 U.S.C.
> 651 et seq. and 45 CFR 303.7 of the\
> child support enforcement program. Standard forms are designed to
> provide uniformity and standardization\
> for interstate case processing. Public reporting burden for this
> collection of information is estimated to\
> average under half an hour per response. The responses to this
> collection are mandatory in accordance\
> with the above statute and regulation. This information is subject to
> State and Federal confidentiality\
> requirements; however, the information will be filed with the tribunal
> and/or agency in the responding State\
> and may, depending on State law, be disclosed to other parties. An
> agency may not conduct or sponsor,\
> and a person is not required to respond to, a collection of
> information unless it displays a currently valid\
> OMB control number.
>
> General Testimony Page 17 of 17