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GENERAL TESTIMONY
Petitioner

Respondent

[ ] IV-D Non Public Assistance [ ] IV-D Non PA Medicaid [ ] Full Services [ ] Medical Services Only [ ] IV-D Public Assistance [ ] IV-E Foster Care (IV-D Case) [ ] Non IV-D

File Stamp

Responding IV-D Case No. __________________________________ Responding Docket No. _____________________________________

Initiating IV-D Case No. __________________________________ Initiating Docket No. _____________________________________

Petitioner is:

[ ] Obligee [ ] Obligor [ ] Obligee [ ] Obligor
Name (First, Middle, Last)

[ ] Caretaker Other than Parent [ ] Foster Care [ ] Caretaker Other than Parent [ ] Foster Care

Respondent is:

___________________________________________________ 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: 3. Full Name

[ ] Obligee

[ ] Obligor

2.

[ ] Nondisclosure Finding Attached
6. Date of Birth 8. Work Phone ( )

(First, Mid, Last; include nickname, alias) Confirmed______________(date)

4. Home Address [ ]

5. Social Security Number 7. Home 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 $ 13. Real or Personal Property (type & location)

12. Other Monthly Income (& source) $

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

[ ] Married 4. [ ] Divorced
1.
General Testimony

[ ] Single 5. [ ] Legally Separated
2.

[ ] Living with Non-Marital Partner 6. [ ] Separated 7. [ ] Unknown
3.
OMB No. 0970 - 0085 Page 1 of 10

GENERAL TESTIMONY, PAGE 2
D. Information about Current Spouse or Partner of Child(ren)'s Mother 1. Name of New Spouse or Non-Marital Partner
(First, Mid, Last)

Initiating IV-D Case No.

2. Is Current Spouse/Partner Employed?

[ ] Yes [ ] No
3. Name and Address of Spouse's/Partner's Employer

[ ] Unknown

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
1. a. Full Name
(First, Mid, Last)

(If yes, provide information below.) b. Date of Birth d. Living With: f. Monthly Amount; Gross: b. Date of Birth d. Living With: f. Monthly Amount; Gross: b. Date of Birth d. Living With: f. Monthly Amount; Gross: Net: Net: Net:

c. Relationship e. Source of Support/Income 2. a. Full Name
(First, Mid, Last)

c. Relationship e. Source of Support/Income 3. a. Full Name
(First, Mid, Last)

c. Relationship e. Source of Support/Income

II. Personal Information About Child(ren)'s Father
A.1. Father is: 3. Full Name

[ ] See Section X

[ ] Obligee

[ ] Obligor

2.

[ ] Nondisclosure Finding Attached
6. Date of Birth 8. Work Phone ( )

(First, Mid, Last; include nickname, alias) Confirmed____________(date)

4. Home Address [ ]

5. Social Security Number 7. Home 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 $ 13. Real or Personal Property (type & location) 12. Other Monthly Income (& source) $

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
C. Present Marital Status of Child(ren)'s Father

Initiating IV-D Case No.

[ ] Married 4. [ ] Divorced
1.

[ ] Single 5. [ ] Legally Separated
2.

[ ] Living with Non-Marital Partner 6. [ ] Separated 7. [ ] Unknown
3. 2. Is Current Spouse/Partner Employed?

D. Information about Current Spouse or Partner of Child(ren)'s Father 1. Name of New Spouse or Non-Marital Partner
(First, Mid, Last)

[ ] Yes [ ] No
3. Name and Address of Spouse's/Partner's Employer

[ ] Unknown

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
1. a. Full Name
(First, Mid, Last)

(If yes, provide information below.) b. Date of Birth d. Living With: f. Monthly Amount; Gross: b. Date of Birth d. Living With: f. Monthly Amount; Gross: Net: Net:

c. Relationship e. Source of Support/Income 2. a. Full Name
(First, Mid, Last)

c. Relationship e. Source of Support/Income

3.

a. Full Name

(First, Mid, Last)

b. Date of Birth d. Living With: f. Monthly Amount; Gross: Net:

c. Relationship e. Source of Support/Income

III. Personal Information About Caretaker Other than Parent
1. Caretaker's Relation to Child is: 3. Full Name
(First, Mid, Last; include nickname, alias) Confirmed____________(date)

[ ] See Section X

2.

[ ] Nondisclosure Finding Attached
6. Date of Birth 9. Work Phone ( ) 7. Sex

4. Home Address [ ]

5. Social Security Number 8. Home 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 $ 14. Date Child(ren) Began Residing With Caretaker 13. Other Monthly Income (& source) $

General Testimony

Page 3 of 10

GENERAL TESTIMONY, PAGE 4

Initiating IV-D Case No.

IV. Legal Relationship of Parents
1. 3. 4. 6. 7. 9.

[ ] See Section X
County/State

[ ] Never married to each other [ ] Separated on _______________
Date

2.

[ ] Married on _______________________in ______________________________
Date Dates County/State

[ ] Married by common law for the period __________________________in_____________________________________
5.

[ ] Divorced on ________________in_____________________________
Date County/State County/State

[ ] Legally separated on___________________in________________________________
Date

[ ] Divorce pending in________________________________
County/State

8.

[ ] Support Order Entered on ____________________
Date

[ ] No support order

10.

[ ] Other______________________________________________________________

11. Tribunal & Location (Divorce, Legal Separation, Support Order):

V. Dependent Child(ren) in this Action
A. List obligor's (named on page 1 of this form) child(ren) only. 1. a. Full Name b. Address
(First, Mid, Last)

[ ] See Section X [ ] Nondisclosure Finding Attached
f. Paternity Established?

[ ] Yes [ ] Yes

[ ] No [ ] No [ ] No

g. Support Order Established?

c. Social Security Number d. Sex 2. a. Full Name b. Address e. Date of Birth
(First, Mid, Last)

h. Living with Petitioner?

[ ] Yes

f. Paternity Established?

[ ] Yes [ ] Yes

[ ] No [ ] No [ ] No

g. Support Order Established?

c. Social Security Number d. Sex 3. a. Full Name b. Address e. Date of Birth
(First, Mid, Last)

h. Living with Petitioner?

[ ] Yes

f. Paternity Established?

[ ] Yes [ ] Yes

[ ] No [ ] No [ ] No

g. Support Order Established?

c. Social Security Number d. Sex e. Date of Birth

h. Living with Petitioner?

[ ] Yes

General Testimony

Page 4 of 10

GENERAL TESTIMONY, PAGE 5
4. a. Full Name b. Address
(First, Mid, Last)

Initiating IV-D Case No. f. Paternity Established?

[ ] Yes [ ] Yes

[ ] No [ ] No [ ] No

g. Support Order Established?

c. Social Security Number d. Sex e. Date of Birth

h. Living with Petitioner?

[ ] Yes

B. The child(ren) began residing in ___________________________ on ____________________________.
State Month/Year

VI. Medical Insurance

[ ] See Section X [ ] Yes [ ] Yes [ ] No [ ] No

1. Is obligor required by a child support order to provide medical insurance for the child(ren)? 2. Is obligor required by a child support order to provide medical insurance for the obligee?

3. Medical coverage for dependent child(ren) listed in Section V and/or the obligee is provided by: For dependent child(ren) Obligee Obligor State Medicaid Obligee's Employer Obligor's Employer Other ___________________ Unknown No Coverage For obligee Obligee's Insurance Company:

[ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ]

[ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ]
Policy Number: Obligor's Insurance Company:

Policy Number: Other Insurance Company:

Policy Number: $____________________

4. The monthly cost paid by the obligee for medical insurance for the obligor's child(ren) only is: (If medical insurance is provided by the obligee or obligee's employer, skip to number 6). 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
1. Does a support order exist? (If "No", skip to page 7.)

[ ] See Section X [ ] No

[ ] Yes

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 a 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 Unpaid Interest $ Tribunal's Name & Address Date of Order Unpaid Interest $ Tribunal's Name & Address Date of Order Unpaid Interest $ Tribunal's Name & Address 5. Unpaid Medical Cost Reimbursement (attach documentation) 6. Other Unpaid Costs and Fees $____________________ as of _________________________
Date

Current Amount $ as of

Per Month/Week/etc. (date)

Toward Arrears $ as of

Per Month/Week/etc. (date)

Total Arrears $

Current Amount $ as of

Per Month/Week/etc. (date)

Toward Arrears $ as of

Per Month/Week/etc. (date)

Total Arrears $

Current Amount $ as of

Per Month/Week/etc. (date)

Toward Arrears $ as of

Per Month/Week/etc. (date)

Total Arrears $

$____________________ as of _________________________
Date

Explain: ______________________________________________________________________________________________ 7. Direct Payments to Obligee:

[ ] Affidavit from Obligee Attached
[ ]Payment history provided on page 6a.

[ ] No Direct Payments Received
[ ]N.A.; responding State does not require.
(Skip to page 7).

8. Obligor's support payment history:

[ ]Certified copy of tribunal/agency payment
history is attached. (Skip to page 7).

From (Year) to (Year):

Agency Which Prepared Audit/Payment History:

General Testimony

Page 6 of 10

GENERAL TESTIMONY, PAGE 6a
Obligor's Payment History Year: ______________________ Amount Due Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total Year: ______________________ Amount Due Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total Amount Paid Balance Amount Paid Balance

Initiating IV-D Case No.
Date of Order

Adjudicated Arrears $____________________ as of ____________________ Year: ______________________ Amount Due Amount Paid Balance

Year: ______________________ Amount Due Amount Paid Balance

Total of Adjudicated and Accrued Arrears $_____________________ as of ___________________________
Date

________________________
Date

__________________________________________
Name/Title, Agency or Tribunal

____________________________________
Signature

________________________
Sworn to and Signed before me this Date, County, State

__________________________________________
Notary Public, Tribunal/Agency Official and Title

____________________________________
Commission Expires

General Testimony

Page 6a of 10

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:_______________/__________ To:_______________/__________by:____________________________
First month year Last month year 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
A. Monthly Income from All Sources:
1. Is the petitioner employed?

[ ] See Section X

Information required varies based on responding State's guidelines. Updates may be required.

[ ] 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 $________________ $________________ l) Spousal support/alimony m) All other sources $________________ 3. Total Gross Monthly (lines "2a" through "2m") 4. Deductions From Gross a) Federal Income Tax
General Testimony

$_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ k) Child support $________________ $_______________ $_______________

$________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________

$________________ $________________ $________________ $________________

$________________

$________________ $________________

$________________

$_______________ $________________ $________________ $________________

Explain "other sources":______________________________________________________ $_______________ $________________ $________________

$_______________

$________________

$________________
Page 7 of 10

b) State Income Tax c) Local Tax d) F.I.C.A.

$_______________ $_______________ $_______________

$________________ $________________ $________________

$________________ $________________ $________________

General Testimony

Page 7 of 10

GENERAL TESTIMONY, PAGE 8
Petitioner 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) $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________

Initiating IV-D Case No. Current Spouse/Partner $________________ Obligor's Dependent(s) $________________

$________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________

$________________ $________________ $________________ $________________

$________________ $________________ $________________

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.

B. Monthly Expenses:

Obligor's Dependent(s) Petitioner 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
C. Assets:

Initiating IV-D Case No.

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

_______________ _______________ __________ $_____________ minus $_____________=
Make Model Year Estimated Value Loan Balance

$_________________ $_________________ $_________________

_______________ _______________ __________ $_____________ minus $_____________=
Make Model Year Estimated Value Loan Balance

_______________ _______________ __________ $_____________ minus $_____________=
Make Model Year Estimated Value 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 X. Other Pertinent Information

Initiating IV-D Case No. (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 (Name/Title)

____________________________________
Signature

______________________
Sworn to and Signed Before me
General Testimony

___________________________________________
Notary Public, Tribunal/Agency

____________________________________
Commission Expires Page 10 of 10

This Date

County/State

Official and Title

General Testimony

Page 10 of 10

INSTRUCTIONS FOR GENERAL TESTIMONY

OMB No. 0970 - 0085

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 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. I II III IV V VI Description Personal Information About Child(ren)'s Mother Personal Information About Child(ren)'s Father Caretaker's Personal Information Legal Relationship of Parents Dependent Child(ren) in this Action Medical Insurance Case Type Requiring Completion All All Cases where the caretaker is an individual other than the child(ren)'s parent All All All, except non-Public Assistance, non-Medicaid cases where applicant requests that medical support not be sought All cases where an order for support has been entered 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 Cases where the obligee received public assistance Establishment and modification cases, as required by States' guidelines When needed (Note: all section headings contain a comments/remarks are desired or required.) XI Verification All

VII Page 6a

Support Order and Payment Information Obligor's Payment History

VIII IX X

Obligee's Public Assistance Status Financial Information Other Pertinent Information checkbox to be used when additiona

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

Instructions for General Testimony--Page 1

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]. 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 completed "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 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

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 (nonhispanic), 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 completed "Locate Data Sheet".

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 (Full, 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 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. 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 (nonhispanic), 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 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 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: 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 the date it was confirmed. If the employer name and address cannot be confirmed, provide last known information. Item 11(a): Enter the father'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 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.

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 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 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.

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 not answer this item; skip to item 6. Otherwise, enter the monthly cost to the obligee if he/she were to provide

Instructions for General Testimony--Page 9

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. 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. 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 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.

#

#

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 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 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 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.
Instructions for General Testimony--Page 11

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 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 public assistance 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 public assistance was 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 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 or documentation, such as receipts. SECTION IX, FINANCIAL INFORMATION: This section is used to obtain information needed to apply guidelines to determine the appropriate amount of support.
Instructions for General Testimony--Page 12

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 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.

Instructions for General Testimony--Page 13

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. 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.

Instructions for General Testimony--Page 14

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. 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.
Instructions for General Testimony--Page 15

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 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. 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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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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