New York Codes, Rules and Regulations › Title 22 - JUDICIARY › Subtitle D - Forms › Chapter IV - Forms of the Family Court of the State of New York and Adoption Forms of the Family Court of the State of New York (cf. s205.7) › Subchapter A - Forms Authorized by Section 205.7 › Uniform Interstate Family Support Act Forms › Form UIFSA-5 - General testimony

Current through Register Vol. 46, No. 28, July
					 10, 2024
F.C.A. Art. 5-B UIFSA-5
GENERAL TESTIMONY
____________
Petitioner [ ] IV-D Non Public
						Assistance
[ ] IV-D Non PA Medicaid
[ ] Full Services
[ ] Medical Services Only
Respondent [ ] IV-D Public
						Assistance
[ ] IV-E Foster Care (IV-D Case)
[ ] Non IV-D
File Stamp
Responding IV-D Case No. ________
						Initiating IV-D Case No. ____________
Responding Docket No. ________ Initiating
						Docket No. ____________
____________
Petitioner is: [ ] Obligee [ ] Caretaker
						Other than Parent
[ ] Obligor [ ] Foster Care
Respondent is: [ ] Obligee [ ] Caretaker
						Other than Parent
[ ] Obligor [ ] Foster Care
______________
Name (First, Middle, Last) being duly
						sworn, under penalties of perjury,
testifies as follows:
I. Personal Information About Child(ren)'s
						Mother [ ] See Section X
A.1. Mother is [ ] Obligee [ ]
									 Obligor
2. [ ] Nondisclosure Finding
									 Attached
3. Full Name (First, Mid, Last; include
									 nickname, alias)
4. Home Address [ ] Confirmed
									 (date)
5. Social Security Number
6. Date of Birth
7. Home Phone ()
8. Work Phone ()
9. Employer Name & Address [ ] Confirmed
									 (date)
10(a). Occupation, Trade or
									 Profession
10(b). Highest Level of Education
									 Attained
11. Estimated Gross Monthly Earnings
									 $
12. Other Monthly Income (& source)
									 $
13. Real or Personal Property (type &
									 location)
B. Physical Description of Child(ren)'s Mother (Optional:
						Attach photo if available.)
1. Race
2. Height
3. Weight
4. Hair Color
5. Eye Color
C. Present Marital Status of Child(ren)'s Mother
1. [ ] Married
2. [ ] Single
3. [ ] Living with Non-Marital
									 Partner
4. [ ] Divorced
5. [ ] Legally Separated
6. [ ] Separated
7. [ ] Unknown
____________
General Testimony OMB No. 0970-0085 Page 1
						of 10
GENERAL TESTIMONY, PAGE 2
Initiating IV-D Case No.
____________
D. Information about Current Spouse or
						Partner of Child(ren)'s Mother
1. Name of New Spouse or Non-Marital Partner
									 (First, Mid, Last)
2. Is Current Spouse/Partner Employed? [ ] Yes
									 [ ] No [ ] Unknown
3. Name and Address of Spouse's/Partner's
									 Employer
4. Spouse's/Partner's Estimated Gross Monthly
									 Earnings $
E. Is the child(ren)'s mother responsible
						for dependents other than those listed in Section V (pages 4 & 5)?
[ ] Yes [ ] No [ ] Unknown (if yes,
						provide information below.)
1. a. Full Name (First, Mid, Last) b. Date
						of Birth
____________
c. Relationship d. Living With:
____________
e. Source of Support/Income f. Monthly
						Amount; Gross: Net:
____________
2. a. Full Name (First, Mid, Last) b. Date
						of Birth
____________
c. Relationship d. Living With:
____________
e. Source of Support/Income f. Monthly
						Amount; Gross: Net:
____________
3. a. Full Name (First, Mid, Last) b. Date
						of Birth
____________
c. Relationship d. Living With:
____________
e. Source of Support/Income f. Monthly
						Amount; Gross: Net:
____________
II. Personal Information About Child(ren)'s Father
						[ ] See Section X
A.1. Father is [ ] Obligee [ ]
									 Obligor
2. [ ] Nondisclosure Finding
									 Attached
3. Full Name (First, Mid, Last; include
									 nickname, alias)
4. Home Address [ ] Confirmed
									 (date)
5. Social Security Number
6. Date of Birth
7. Home Phone ()
8. Work Phone ()
9. Employer Name & Address [ ] Confirmed
									 (date)
10(a). Occupation, Trade or
									 Profession
10(b). Highest Level of Education
									 Attained
11. Estimated Gross Monthly Earnings
									 $
12. Other Monthly Income (& source)
									 $
13. Real or Personal Property (type &
									 location)
B. Physical Description of Child(ren)'s
						Father (Optional: Attach photo if available.)
1. Race
2. Height
3. Weight
4. Hair Color
5. Eye Color
____________
General Testimony Page 2 of 10
GENERAL TESTIMONY, PAGE 3
Initiating IV-D Case No.
____________
C. Present Marital Status of Child(ren)'s
						Father
1. [ ] Married
2. [ ] Single
3. [ ] Living with Non-Marital
									 Partner
4. [ ] Divorced
5. [ ] Legally Separated
6. [ ] Separated
7. [ ] Unknown
D. Information about Current Spouse or Partner of
						Child(ren)'s Father
1. Name of New Spouse or Non-Marital Partner
									 (First, Mid, Last)
2. Is Current Spouse/Partner Employed? [ ] Yes
									 [ ] No [ ] Unknown
3. Name and Address of Spouse's/Partner's
									 Employer
4. Spouse's/Partner's Estimated Gross Monthly
									 Earnings $
E. Is the child(ren)'s father responsible
						for dependents other than those listed in Section V (pages 4 & 5)?
[ ] Yes [ ] No [ ] Unknown (if yes,
						provide information below.)
1. a. Full Name (First, Mid, Last) b. Date
						of Birth
____________
c. Relationship d. Living With:
____________
e. Source of Support/Income f. Monthly
						Amount; Gross: Net:
____________
2. a. Full Name (First, Mid, Last) b. Date
						of Birth
____________
c. Relationship d. Living With:
____________
e. Source of Support/Income f. Monthly
						Amount; Gross: Net:
____________
3. a. Full Name (First, Mid, Last) b. Date
						of Birth
____________
c. Relationship d. Living With:
____________
e. Source of Support/Income f. Monthly
						Amount; Gross: Net:
____________
III. Personal Information About Caretaker Other
						than Parent [ ] See Section X
1. Caretaker's Relation to Child
									 is:
2. [ ] Nondisclosure Finding
									 Attached
3. Full Name (First, Mid, Last; include
									 nickname, alias)
4. Home Address [ ] Confirmed
									 (date)
5. Social Security Number
6. Date of Birth 7. Sex
8. Home Phone ()
9. Work Phone ()
10. Employer Name & Address [ ] Confirmed
									 (date)
11(a). Occupation, Trade or
									 Profession
11(b). Highest Level of Education
									 Attained
12. Estimated Gross Monthly Earnings
									 $
13. Other Monthly Income (& source)
									 $
14. Date Child(ren) Began Residing with
									 Caretaker
____________
General Testimony Page 3 of 10
GENERAL TESTIMONY, PAGE 4
Initiating IV-D Case No.
____________
IV. Legal Relationship of Parents [ ] See
						Section X
1. [ ] Never married to each other 2. [ ]
						Married on
_______
Date in
County/State
3. [ ] Married by common law for the
						period
_______
Dates in
County/State
4. [ ] Separated on
_____
Date 5. [ ] Divorced on
_____
Date in
County/State
6. [ ] Legally separated on
_____
Date in
____________
County/State
7. [ ] Divorce pending in
________
County/State 8. [ ] Support Order Entered
						on
_____
Date
9. [ ] No support order 10. [ ] Other
						____________
11. Tribunal & Location (Divorce,
						Legal Separation, Support Order):
V. Dependent Child(ren) in this Action [ ]
						See Section X
A. List obligor's (named on page 1 of this
						form) child(ren) only. [ ] Nondisclosure Finding Attached
1. a. Full Name (First, Mid, Last) f.
						Paternity Established?
b. Address [ ] Yes [ ] No
g. Support Order Established?
[ ] Yes [ ] No
c. Social Security Number h. Living with
						Petitioner?
d. Sex e. Date of Birth [ ] Yes [ ]
						No
2. a. Full Name (First, Mid, Last) f.
						Paternity Established?
b. Address [ ] Yes [ ] No
g. Support Order Established?
[ ] Yes [ ] No c. Social Security Number
						h. Living with Petitioner?
d. Sex e. Date of Birth [ ] Yes [ ]
						No
3. a. Full Name (First, Mid, Last) f.
						Paternity Established?
b. Address
[ ] Yes [ ] No
g. Support Order Established?
[ ] Yes [ ] No
c. Social Security Number h. Living with
						Petitioner?
d. Sex e. Date of Birth [ ] Yes [ ]
						No
____________
General Testimony Page 4 of 10
GENERAL TESTIMONY, PAGE 5
Initiating IV-D Case No.
____________
4. a. Full Name (First, Mid, Last) f.
						Paternity Established?
b. Address [ ] Yes [ ] No
g. Support Order Established?
[ ] Yes [ ] No
c. Social Security Number h. Living with
						Petitioner?
d. Sex e. Date of Birth [ ] Yes [ ]
						No
B. The child(ren) began residing in
______
State on
______
Month/Year.
VI. Medical Insurance [ ] See Section
						X
1. Is obligor required by a child support
						order to provide medical insurance for the child(ren)? [ ] Yes [ ] No
2. Is obligor required by a child support
						order to provide medical insurance for the obligee? [ ] Yes [ ] No
3. Medical coverage for dependent
						child(ren) listed in Section V and/or the obligee is provided by:
For dependent
									 child(ren)
For obligee
Obligee
[ ]
[ ]
Obligee's Insurance Company:
Obligor
[ ]
[ ]
Policy Number:
State Medicaid
[ ]
[ ]
Obligee's Employer
[ ]
[ ]
Obligor's Insurance Company:
Obligor's Employer
[ ]
[ ]
Policy Number:
Other
[ ]
[ ]
Unknown
[ ]
[ ]
Other Insurance Company:
No coverage
[ ]
[ ]
Policy Number:
4. The monthly cost paid by the obligee
						for medical insurance for the obligor's child(ren) only is: $ ________
(e) All pleadings, briefs or memor and a
						which reproduce, paraphrase or disclose any documents which have previously
						been designated by a party as comprising or containing Confidential Information
						or "Highly Confidential - Attorney's Eyes-Only Information" shall identify such
						documents by the production number ascribed to them at the time of
						production.
5. Obligee can purchase needed medical
						insurance at a monthly cost of:
$ ________
6. Were the children ever covered by
						medical insurance provided by the obligor/obligee, or his/her current employer?
						[ ] Yes [ ] No [ ] Unknown
7. Do any of the obligor's children have
						special needs or extraordinary medical expenses not covered by insurance? [ ]
						Yes [ ] No
(If "Yes", please indicate the child
						involved and the type of special needs/extraordinary medical expenses and the
						related costs. Attach proof.)
____________
General Testimony Page 5 of 10
GENERAL TESTIMONY, PAGE 6
Initiating IV-D Case No.
____________
VII. Support Order and Payment Information
						[ ] See Section X
1. Does a support order exist? (If "No",
						skip to page 7.) [ ] Yes [ ] No
2. Did child(ren) reside with the obligor
						at anytime during the period for which support is sought, except during periods
						of visitation specified by a tribunal's order? [ ] Yes [ ] No If "Yes",
						Identify Period of Residency: From: Thru:
3. If a modification is being requested,
						indicate the basis for the request below:
[ ] The earnings of the obligor have
						substantially increased or decreased.
[ ] The earnings of the obligee have
						substantially increased or decreased.
[ ] The needs of the party or of the
						child(ren) have substantially increased or decreased.
[ ] Other, Explain ____________
4. Describe all current support orders
						(include all pertinent orders and modifications). NOTE: if more than three (3)
						orders exist, attach complete description as below for each.
Date of Order
Current Amount $
Per Month/Week/etc.
Toward Arrears $
Per Month/Week/etc.
Unpaid Interest $ as of (date) Total Arrears $
									 as of (date)
Tribunal's Name & Address
Date of Order
Current Amount $
Per Month/Week/etc.
Toward Arrears $
Per Month/Week/etc.
Unpaid Interest $ as of (date) Total Arrears $
									 as of (date)
Tribunal's Name & Address
Date of Order
Current Amount $
Per Month/Week/etc.
Toward Arrears $
Per Month/Week/etc.
Unpaid Interest $ as of (date) Total Arrears $
									 as of (date)
Tribunal's Name & Address
5. Unpaid Medical Cost Reimbursement
						$________ as of
________
Date
(attach documentation)
6. Other Unpaid Costs and Fees $________
						as of
________
Date
Explain: ____________
7. Direct Payments to Obligee: [ ]
						Affidavit from Obligee Attached [ ] No Direct Payments Received
8. Obligor's support payment
						history:
[ ]Certified copy of tribunal/agency
						payment [ ]Payment history provided on page 6a.[ ]N.A.; responding State does
						not require.
history is attached. (skip to page 7).
						(Skip to page 7).
From (Year) to (Year):
Agency Which Prepared Audit/Payment
									 History:
____________
General Testimony Page 6 of 10
Image
GENERAL TESTIMONY, PAGE 7
Initiating IV-D Case No.
____________
VIII. Obligee's Public Assistance Status [
						] See Section X
[If no public assistance was paid, skip to
						Section IX.]
1. Period during which public assistance
						was paid:
From:
____
First month/
___
year To:
____
Last month/
___
year by
_____
State
2. Total amount of public assistance paid:
						$ ________ as of
_____
Date
3. Medical assistance related to prenatal,
						postnatal, or general expenses was paid in the amount of $ ____________
by
Agency or Person.
IX. Financial Information [ ] See Section
						X
Information required varies based on
						responding State's guidelines. Updates may be required.
A. Monthly Income from All Sources
1. Is the petitioner employed? [ ] Yes;
						occupation: ________ [ ] No; income source: ________
Petitioner
Current Spouse/
									 Partner
Obligor's
									 Dependent(s)
2. Gross Monthly Income Amounts:
a) Public Assistance
i) SSI
$
$
$
ii) Family Assistance
$
$
$
iii) Other
$
$
$
b) Base pay salary, wages
$
$
$
c) Overtime, commissions, tips, bonuses,
									 parttime
$
$
$
d) Unemployment compensation
$
$
$
e) Worker's compensation
$
$
$
f) Social Security Disability
$
$
$
g) Social Security Retirement
$
$
$
h) Dividends and interest
$
$
$
i) Trust/Annuity Income
$
$
$
j) Pensions, retirement
$
$
$
k) Child support
$
$
$
l) Spousal support/alimony
$
$
$
m) All other sources
$
$
$
Explain "other sources":
3. Total Gross Monthly (lines "2a" through
									 "2m")
$
$
$
4. Deductions From Gross
a) Federal Income Tax
$
$
$
b) State Income Tax
$
$
$
c) Local Tax
$
$
$
d) F.I.C.A.
$
$
$
____________
General Testimony Page 7 of 10
GENERAL TESTIMONY, PAGE 8
Initiating IV-D Case No.
____________
Petitioner
Current Spouse/
									 Partner
Obligor's
									 Dependent(s)
5. Adjusted Net Monthly (lines "3" minus lines
									 "4a through 4d")
$
$
$
6. Other Deductions
a) Savings
$
$
$
b) Loan Repayment
$
$
$
c) Mandatory Retirement
$
$
$
d) Non-mandatory Retirement
$
$
$
e) Medical Insurance
$
$
$
f) Union Dues
$
$
$
g) Other (specify)
$
$
$
7. Net Monthly Income (line 5 minus lines "6a
									 through 6g")
$
$
$
8. Gross Income Prior Year
$
$
$
Attach three most recent paystubs from
						each current employer for all parties shown.
Petitioner
Obligor's
									 Dependent(s)
B. Monthly Expenses:
1) Rent/Mortgage
$
$
2) Homeowners/Renters Insurance
$
$
3) Home Maintenance & Repair
$
$
4) Heat
$
$
5) Electricity/Gas
$
$
6) Telephone
$
$
7) Water/Sewer
$
$
8) Food
$
$
9) Laundry/Cleaning
$
$
10) Clothing
$
$
11) Life Insurance
$
$
12) Medical Insurance
$
$
13) Uninsured Extraordinary Medical (attach
									 documentation)
$
$
14) Other Uninsured Health-Related
									 Expenses
$
$
15) Auto Payment
$
$
16) Auto Insurance
$
$
17) Auto Expenses
$
$
18) Other Transportation
$
$
19) Child Care
$
$
Provider:
Frequency:
20) Support Payments, actual amount
									 paid
$
$
21) Other, Explain:
$
$
Total Monthly Expenses (lines 1 through
									 21)
$
$
____________
General Testimony Page 8 of 10
GENERAL TESTIMONY, PAGE 9
Initiating IV-D Case No.
____________
C. Assets:
1) Real Estate
_______________
Address
_______________
Owner(s)
_______________
Title
$
______
Assessed Value minus $
______
Mortgage(s) = $ ____________
2) IRA, Keogh, Pension, Profit Sharing,
						Other Retirement Plans
__________________
Institution or Plan Name and Account No. $
						____________
__________________
Institution or Plan Name and Account No. $
						____________
3) Tax Deferred Annuity Plan(s) $
						________
4) Life Insurance: Present Cash Value $
						________
5) Savings & Checking Accounts, Money
						Market Accounts, & CDs
__________________
Institution Name and Account Number $
						____________
__________________
Institution Name and Account Number $
						____________
6) Automobiles/Vehicles
___
Make
___
Model
__
Year $
____
Estimated Value minus $
___
Loan Balance = $ ____________
___
Make
___
Model
__
Year $
____
Estimated Value minus $
___
Loan Balance = $ ____________
___
Make
___
Model
__
Year $
____
Estimated Value minus $
___
Loan Balance = $ ____________
7) Other (e.g., Personal Property,
						Securities, etc). Describe:
________ $ ________
________ $ ________
Total Assets (lines 1 through 7) $
						________
____________
General Testimony Page 9 of 10
GENERAL TESTIMONY, PAGE 10
Initiating IV-D Case No.
____________
X. Other Pertinent Information (Attach
						additional sheets if necessary).
____________
XI. Verification
[ ] Attached are the required number of
						copies of all support orders for the case.
Also attached and incorporated by
						reference are:
[ ] Copy of the certified child support
						payment records.
[ ] Copies of three most recent paystubs
						from current employer.
[ ] Copies of bills for prenatal,
						postnatal and general health care of mother and child.
[ ] Assignment or subrogation of support
						rights.
[ ] "Affidavit in Support of Establishing
						Paternity" for each child whose paternity is at issue.
[ ] Copy of child(ren)'s birth
						certificate(s).
[ ] Acknowledgment of parentage.
[ ] Other: ____________
All of the information and facts contained
						in this General Testimony are true and correct to my/our best knowledge and
						belief.
__________
Date
__________
Petitioner (Name/Title)
_______
Signature
__________
Date
_______
Agency Representative
__________
Signature
(Name/Title)
__________
Sworn to and Signed Before me
__________
Notary Public, Tribunal/Agency
_______
Commission Expires
This Date County/State Official and
						Title
____________
General Testimony Page 10 of 10
OMB No. 0970 - 0085
INSTRUCTIONS FOR GENERAL TESTIMONY
PURPOSE OF THE FORM: 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 a check box 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
Caretaker's Personal Information
Cases where the caretaker is an individual
									 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, except non-Public Assistance, non-Medicaid
									 cases where applicant requests that medical support not be sought
VII
Support Order and Payment
									 Information
All cases where an order for support has been
									 entered
Page 6a
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
Obligee's Public Assistance Status
Cases where the obligee received public
									 assistance
IX
Financial Information
Establishment and modification cases, as
									 required by State's guidelines
X
Other Pertinent Information
When needed (Note: all section headings contain
									 a check box to be used when additional comments/remarks are desired or
									 required.)
XI
Verification
All
HEADING/CAPTION:
Identify the petitioner and respondent in
						the appropriate spaces.
Check the appropriate space to identify
						the type of case: IV-D Non Public Assistance; IV-D Non Public Assistance
						Medicaid (indicate whether receiving Full Child Support Services or Medical
						Services Only); IV-D Public Assistance; IV-D Foster Care (IV-E); or Non IV-D.
						IV-D means the case is being worked by the State or local child support
						enforcement agency (i.e., IV-D agency). Public Assistance means the obligee's
						family receives IV-A cash payments [IV-A was formerly called Aid to Families
						with Dependent Children (AFDC) and is now called Temporary Family
						Assistance].
____________
Instructions for General Testimony--Page
						1
IV-D Non Public Assistance means that the
						obligee applied for child support enforcement services but is not receiving
						public assistance (IV-A cash payments).
IV-D Non Public Assistance Medicaid means
						that the obligee is not 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".
IV-D Public Assistance 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 Family Assistance]. In
						exchange for receiving benefits, a person receiving public assistance agrees to
						"assign her support rights" or to turn over to the State any right to child
						support payments paid by the obligated parent.
IV-E Foster Care 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.
Non IV-D means the case is a private case
						that is not being worked by the State or local child support enforcement or
						IV-D agency.
Under "Responding IV-D Case No." and
						"Responding Docket No.", enter appropriate case and docket numbers that the
						responding State uses to identify the case, if applicable and if known. Under
						"docket number", you may enter the docket number, cause number, or any other
						appropriate reference number.
Under "Initiating IV-D Case No." and
						"Initiating Docket No.", enter appropriate case and docket numbers which your
						IV-D agency or local tribunal has assigned to the case. Under "docket 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 is the individual or State agency
						who is owed or is alleged to be owed support. If an obligee receives public
						assistance, she assigns her support rights to the State.
Obligor 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 is an
						individual who is custodian of the child(ren) but who is not the mother or
						father of the child(ren).
Foster Care 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.
____________
Instructions for General Testimony--Page
						2
SECTION I, PERSONAL INFORMATION ABOUT
						CHILD(REN)'S MOTHER: This section asks for information about the child(ren)'s
						mother. If the mother is the respondent in this action, this information will
						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 mother is the respondent and needs to be located, also attach a competed
						"Locate Data Sheet".
If the individual completing this form is
						not the child(ren)'s mother, that individual may not be able to provide all of
						the requested information. 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), including nickname or alias.
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.
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 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
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Instructions for General Testimony--Page
						3
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 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 INFORMATION ABOUT
						CHILD(REN)'S FATHER: 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 father is the respondent and needs to be located, also attach a competed
						"Locate Data Sheet".
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Instructions for General Testimony--Page
						4
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.
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
						(First, Middle, Last), including nickname or alias.
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.
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 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. Optional: 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.
____________
Instructions for General Testimony--Page
						5
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.
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 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 father 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, provided 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 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: 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".
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), including nickname or alias.
____________
Instructions for General Testimony--Page
						6
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.
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.
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 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:
						Identify the legal relationship between the child(ren)'s mother and father.
						Check 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.
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Instructions for General Testimony--Page
						7
Item 6: Check this box if the parents are
						legally separated. Indicate the date (Month, Date, Year) and County/State of
						the legal separation.
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). If you are sending this case to a State that uses the Uniform
						Interstate Family Support Act (UIFSA), you will generally need to attach two
						copies, one of which is certified, of any support order. If you are sending
						this case to a State that uses a version of the Uniform Reciprocal Enforcement
						of Support Act (URESA), you will generally need to attach three certified
						copies of any support order. Note, however, that some responding States may be
						able to take certain administrative enforcement actions (e.g., interstate wage
						withholding) without having a certified copy of the order, although a regular
						copy is still necessary.
SECTION V, DEPENDENT CHILD(REN) IN THIS
						ACTION: This information is used to identify child(ren) for whom paternity is
						to be established and/or for whom 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 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 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 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.
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Instructions for General Testimony--Page
						8
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 whether the father's paternity of the child has been
						established.
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 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: 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 except those non-Public
						Assistance, non-Medicaid cases, where the applicant requests that medical
						coverage not be sought.
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", list
						in the blank 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 no 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.
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Instructions for General Testimony--Page
						9
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.
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 theses costs including agreements that are verbal, written, or
						part of any court or administrative order.
SECTION VII, SUPPORT ORDER AND PAYMENT
						INFORMATION: 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 appropriate
						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.
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Instructions for General Testimony--Page
						10
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.
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. If you are sending this
						case to a State that uses the Uniform Interstate Family Support Act (UIFSA),
						you will generally need to attach two copies, one of which is certified, of any
						support order. If you are sending this case to a State that uses a version of
						the Uniform Reciprocal Enforcement of Support Act (URESA), you will generally
						need to attach three certified copies of any support order. Note, however, that
						some responding States m may be able to take certain administrative enforcement
						actions (e.g., interstate wage withholding) 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 the 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 cost/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 coy 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".
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Instructions for General Testimony--Page
						11
PAGE 6A: Complete this page if you checked
						the middle box in item 8, section VII, page 6. Enter the amount of adjudicated
						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 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, OBLIGEE'S PUBLIC ASSISTANCE
						STATUS: Complete this section only if:
You are seeking support for a prior period
						and public assistance was paid, or
You are seeking reimbursement for medical
						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 the 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 public assistance may be a relevant factor in setting an award
						for a prior period; this section provides spaces 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 public assistance was paid tot he 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 public assistance 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 of
						documentation, such as receipts.
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Instructions for General Testimony--Page
						12
SECTION IX, FINANCIAL INFORMATION: This
						section is used to obtain 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
						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 you may wish to consult the Interstate Roster and Referral Guide 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. You 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.
						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 Family
						Assistance]. "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 the workers' 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.
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Instructions for General Testimony--Page
						13
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 inkind income, barter, or net
						income from rental property. If income is received on other than a monthly
						basis, annualize and divide by 12.
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 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 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.
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Instructions for General Testimony--Page
						14
Attach the three most recent paystubs 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 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.
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Instructions for General Testimony--Page
						15
Item 19: Specify the monthly amount paid
						for child care (work-related or otherwise), the provider, and the frequency
						child care is use (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.
Item 20: Enter the monthly amount of any
						support payments actually made by the individual petitioner for child, spousal
						or family support.
Item 21: 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 bottom of
						page 8, add the totals of line 1 through line 21 and enter the total on the
						lines beside Total Monthly Expenses for both 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.
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.
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:
						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: Attach the
						appropriate number of copies of any existing support order, and check the box
						indicating that the copies are attached. If you are sending this case to a
						State that uses the Uniform Interstate Family Support Act (UIFSA), you will
						generally need to attach two copies, one of which is certified, of any support
						order. If you are sending this case to a State that uses a version of the
						Uniform Reciprocal Enforcement of Support Act (URESA), you will generally need
						to attach three certified copies of any support order. Note, however, that some
						responding States may be able to take certain administrative enforcement
						actions (e.g., interstate wage withholding) without having a certified 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.
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Instructions for General Testimony--Page
						16
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 paystubs 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; 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" 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" 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 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 the individual
						petitioner's signature; check with the Interstate Roster and Referral Guide 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
This information collection is conducted
						in accordance with
						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 one hour per response. The responses to
						this collection are mandatory in accordance with
						45 CFR
						303.7. 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.
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Instructions for General Testimony--Page
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