1 General Testimony

GENERAL TESTIMONY

(Instructions should be provided to the petitioner as part of the form.)

THIS FORM CONTAINS SENSITIVE INFORMATION – DO NOT FILE THIS FORM IN

A PUBLIC ACCESS FILE

The information on this form may be filed with the petition or pleading and may be disclosed to the

parties in the case unless accompanied by a nondisclosure finding/affidavit.

If you are not the intended recipient, you are hereby notified that any use, disclosure, distribution,

or copying of this form or its contents is strictly prohibited.

Personal Information Form for UIFSA § 311 must be attached.

File Stamp

Petitioner: Legal Name (first, middle, last, suffix)

IV-D Case:

[ ]

TANF

[ ]

IV-E Foster Care

[ ] Obligee [ ] Obligor

[ ]

Medicaid Only

Tribal Affiliation (if applicable)

[ ]

Former Assistance

[ ]

Never Assistance

Respondent: Legal Name (first, middle, last, suffix)

Non-IV-D Case:

[ ]

[ ] Obligee [ ] Obligor

Responding IV-D Case Identifier:

_________________________________

Tribal Affiliation (if applicable)

Responding Tribunal Number:

_________________________________

NOTE:

Initiating IV-D Case Identifier:

_________________________________

Initiating Tribunal Number:

_________________________________

[ ] Nondisclosure Finding/Affidavit attached

[ ] This form sent through EDE

I,

_________________________________________

, declare under penalty of perjury:

Legal Name (first, middle, last, suffix)

I. Personal Information About Obligee: (Obligee caretaker complete section I.E only)

[ ] See section IX

A.

Obligee parent information

1.

Legal name (first, middle, last, suffix):

2.

Gender: [ ] Male [ ] Female [ ] Other

3.

a. Occupation, trade, or profession:

b. Highest level of education attained:

4.

Current tax filing status: [ ] Single [ ] Head of household [ ] Married filing jointly [ ] Married filing separately

[ ] Qualifying widow/widower with dependent children [ ] Unknown

B. Physical description of the obligee parent: (Attach a recent photo if available.)

1.

Race:

2.

Height:

3.

Weight:

4.

Hair color:

5.

Eye color:

C. Is the obligee parent financially responsible for dependent children other than those of this action (listed in section IV)?

[ ] Yes [ ] No [ ] Unknown (If yes, provide information below if known.)

1.

a. Legal name (first, middle, last, suffix):

b. Year of birth:

c. Relationship:

d. Living with:

2.

a. Legal name (first, middle, last, suffix):

b. Year of birth:

c. Relationship:

d. Living with:

GENERAL TESTIMONY, PAGE 2

I. Personal Information About Obligee (Continued):

3.

a. Legal name (first, middle, last, suffix):

b. Year of birth:

c. Relationship:

d. Living with:

D. Does the obligee parent have an order to pay support for any child listed in C above? [ ] Yes [ ] No [ ] Unknown

(If yes, fill out information below, if known, and attach a copy of the order and payment record/proof of payment, if available.)

1.

Child(ren) name(s):

Amount:

Frequency:

State and county/tribe/country:

Tribunal number:

2.

Child(ren) name(s):

Amount:

Frequency:

State and county/tribe/country:

Tribunal number:

3.

Child(ren) name(s):

Amount:

Frequency:

State and county/tribe/country:

Tribunal number:

E.

Obligee Caretaker information: (Provide any relevant non-party parent information, including financial information, in section IX.)

1. Caretaker legal name (first, middle, last, suffix):

2. Caretaker relationship to child is: ____________________________ [ ] Has legal custody/guardianship of child

3. Date child(ren) began residing with caretaker:

II. Personal Information About Obligor:

[ ] See section IX

A. Obligor information:

1.

Legal name (first, middle, last, suffix):

2.

Gender: [ ] Male [ ] Female [ ] Other

3.

a. Occupation, trade or profession:

b. Highest level of education attained:

4.

Current tax filing status: [ ] Single [ ] Head of household [ ] Married filing jointly [ ] Married filing separately

[ ] Qualifying widow/widower with dependent children [ ] Unknown

B. Physical description of the obligor: (Attach a recent photo if available.)

1.

Race:

2.

Height:

3.

Weight:

4.

Hair color:

5.

Eye color:

C. Is the obligor financially responsible for dependent children other than those of this action (listed in section IV)?

[ ] Yes [ ] No [ ] Unknown (If yes, provide information below if known.)

1.

a. Legal name (first, middle, last, suffix):

b. Year of birth:

c. Relationship:

d. Living with:

2.

a. Legal name (first, middle, last, suffix):

b. Year of birth:

c. Relationship:

d. Living with:

GENERAL TESTIMONY, PAGE 3

II. Personal Information About Obligor (Continued):

3.

a. Legal name (first, middle, last, suffix):

b. Year of birth:

c. Relationship:

d. Living with:

D. Does the obligor have an order to pay support for any child listed in C above? [ ] Yes [ ] No [ ] Unknown

(If yes, fill out information below, if known, and attach a copy of the order and payment record/proof of payment, if available.)

1.

Child(ren) name(s):

Amount: $

Frequency:

State and county/tribe/country:

Tribunal number:

2.

Child(ren) name(s):

Amount: $

Frequency:

State and county/tribe/country:

Tribunal number:

3.

Child(ren) name(s):

Amount: $

Frequency:

State and county/tribe/country:

Tribunal number

III. Legal Relationship of Parents of Children Listed in Section IV:

[ ] See section IX

A.

[ ] Never married to each other

B.

[ ] Married on

_________________________

in

_____________________________________________

(Date)

(State and county/tribe/country)

C.

[ ] Married by common law for the period

______________________

in

_____________________________

(Dates)

( State and county/tribe/country)

D.

[ ] Legally separated on

________________

in

___________________________________

(Date)

(State and county/tribe/country)

E.

[ ] Divorce pending in

______________________________________

(State and county/tribe/country)

F.

[ ] Divorced on

_____________________

in

___________________________________

(Date)

(State and county/tribe/country)

G.

[ ] Other

__________________________________________________________________________________________

IV. Dependent Child(ren) in This Action:

[ ] See section IX

A.

1. Legal name (first, middle, last, suffix):

2. Parentage established?

[ ] Yes [ ] No

3. Child care expense per month – Total: $ ______________

4. Support order established?

5. Living with petitioner?

State Subsidized: $ ____________

[ ] Yes [ ] No

[ ] Yes [ ] No

Out of Pocket: $______________

6. Does the child receive benefits from Social Security, VA, etc.? [ ] Yes [ ] No (If yes, complete the information below.)

_______________________________________________________ $________________ per month

(Benefit type(s))

Based on claim of _____________________________________ Relationship to child: _______________________

(Name)

7. Tribal Affiliation [ ] Yes [ ] No (If yes, basis of tribal affiliation: ____________________________________)

GENERAL TESTIMONY, PAGE 4

IV. Dependent Child(ren) in This Action (Continued):

B.

1. Legal name (first, middle, last, suffix):

2. Parentage established?

[ ] Yes [ ] No

3. Child care expense per month – Total: $ ______________

4. Support order established?

5. Living with petitioner?

State Subsidized: $ ____________

[ ] Yes [ ] No

[ ] Yes [ ] No

Out of Pocket: $______________

6. Does the child receive benefits from Social Security, VA, etc.? [ ] Yes [ ] No (If yes, complete the information below.)

_______________________________________________________ $________________ per month

(Benefit type(s))

Based on claim of _____________________________________ Relationship to child: _______________________

(Name)

7. Tribal Affiliation [ ] Yes [ ] No (If yes, basis of tribal affiliation: ____________________________________)

C.

1. Legal name (first, middle, last, suffix):

2. Parentage established?

[ ] Yes [ ] No

3. Child care expense per month – Total: $ ______________

4. Support order established?

5. Living with petitioner?

State Subsidized: $ ____________

[ ] Yes [ ] No

[ ] Yes [ ] No

Out of Pocket: $______________

6. Does the child receive benefits from Social Security, VA, etc.? [ ] Yes [ ] No (If yes, complete the information below.)

_______________________________________________________ $________________ per month

(Benefit type(s))

Based on claim of _____________________________________ Relationship to child: _______________________

(Name)

7. Tribal Affiliation [ ] Yes [ ] No (If yes, basis of tribal affiliation: ____________________________________)

V. Health Care Coverage:

[ ] See section IX

A.

Health Care Coverage for Child(ren): For each child listed in section IV, complete the information below.

1.

a.

Child’s name: __________________________________________________________________________________

Does this child have health care coverage? [ ] Yes [ ] No [ ] Unknown (If no or unknown, skip to 1.e.)

b.

Health care coverage is provided by (check all that apply):

[ ] Medicaid (Skip to 1.e.) [ ] CHIP (Skip to 1.e.) [ ] TRICARE (Skip to 1.e.)

[ ] Indian Health Service (Skip to 1.e.)

[ ] Petitioner through an individual policy (Continue to 1.c below.)

[ ] Petitioner through his/her employer (Continue to 1.c below.)

[ ] Respondent through an individual policy (Continue to 1.c below.)

[ ] Respondent through his/her employer (Continue to 1.c below.)

[ ] Other person: _________________________ Relationship to child: _______________ (Complete 1.c below.)

c.

Health care coverage provider name: _______________________________________________________________

Address:

Policy ID number: ____________________________

Group number: ___________________________________

d.

Is this a child only policy? [ ] Yes [ ] No (If yes, what is the monthly premium for this child only? $______________)

e.

Who claims a dependency exemption for the child for federal tax purposes? [ ] Obligee [ ] Obligor [ ] Other

If other, identify the person:

_________________________

Relationship to child:

____________________________

(Attach a copy of any order addressing the dependency exemption.)

f.

Does the individual entitled to claim the dependency exemption change from year to year?

[ ] Yes

[ ] No (If yes, explain.)_____________________________________________________________________________

GENERAL TESTIMONY, PAGE 5

V. Health Care Coverage (Continued):

2.

a.

Child’s name: __________________________________________________________________________________

Does this child have health care coverage? [ ] Yes [ ] No [ ] Unknown (If no or unknown, skip to 2.e.)

If yes, is all the information the same as Child 1? [ ] Yes (Skip to 2.e.) [ ] No (Continue with 2.b.)

b.

Health care coverage is provided by (check all that apply):

[ ] Medicaid (Skip to 2.e.) [ ] CHIP (Skip to 2.e.) [ ] TRICARE (Skip to 2.e.)

[ ] Indian Health Service (Skip to 2.e)

[ ] Petitioner through an individual policy (Continue to 2.c below.)

[ ] Petitioner through his/her employer (Continue to 2.c below.)

[ ] Respondent through an individual policy (Continue to 2.c below.)

[ ] Respondent through his/her employer (Continue to 2.c below.)

[ ] Other person: __________________________ Relationship to child: _______________ (Complete 2.c below.)

c.

Health care coverage provider name: ________________________________________________________________

Address:

Policy ID number: ____________________________

Group number: ___________________________________

d.

Is this a child only policy? [ ] Yes [ ] No (If yes, what is the monthly premium for this child only? $______________)

e.

Who claims a dependency exemption for the child for federal tax purposes? [ ] Obligee [ ] Obligor [ ] Other

If other, identify the person:

_________________________

Relationship to child:

____________________________

(Attach a copy of any order addressing the dependency exemption.)

f.

Does the individual entitled to claim the dependency exemption change from year to year?

[ ] Yes

[ ] No (If yes, explain in section IX.)

3.

a.

Child’s name: __________________________________________________________________________________

Does this child have health care coverage? [ ] Yes [ ] No [ ] Unknown (If no or unknown, skip to 3.e.)

If yes, is all the information the same as Child 1? [ ] Yes (Skip to 3.e.) [ ] No (Continue with 3.b.)

b.

Health care coverage is provided by (check all that apply):

[ ] Medicaid (Skip to 3.e.) [ ] CHIP (Skip to 3.e.) [ ] TRICARE (Skip to 3.e.)

[ ] Indian Health Service (Skip to 3.e)

[ ] Petitioner through an individual policy (Continue to 3.c below.)

[ ] Petitioner through his/her employer (Continue to 3.c below.)

[ ] Respondent through an individual policy (Continue to 3.c below.)

[ ] Respondent through his/her employer (Continue to 3.c below.)

[ ] Other person: _________________________ Relationship to child: _______________ (Complete 3.c. below.)

c.

Health care coverage provider name: ______________________________________________________________

Address:

Policy ID number: ____________________________

Group number: ___________________________________

d.

Is this a child only policy? [ ] Yes [ ] No (If yes, what is the monthly premium for this child only? $______________)

e.

Who claims a dependency exemption for the child for federal tax purposes? [ ] Obligee [ ] Obligor [ ] Other

If other, identify the person:

Relationship to child:

(Attach a copy of any order addressing the dependency exemption.)

f.

Does the individual entitled to claim the dependency exemption change from year to year?

[ ] Yes

[ ] No (If yes, explain in section IX.)

GENERAL TESTIMONY, PAGE 6

V. Health Care Coverage (Continued):

B.

Health Care Coverage for Petitioner: Does the petitioner have health care coverage? [ ] Yes [ ] No (If no, skip to B.4.)

1.

Petitioner’s health care coverage is provided by: [ ] Medicaid (Skip to B.4.) [ ] TRICARE (Skip to C.)

[ ] Indian Health Service (Skip to C.)

[ ] Self through his/her employer (Continue to B.2 below.)

[ ] Self through an individual policy (Continue to B.2 below.)

[ ] Other person: ___________________________ Relationship to petitioner: __________________ (Complete B.2 below.)

2.

Health care coverage provider name: ___________________________________________________________________

Address:

Policy ID number: ____________________________

Group number: _______________________________________

Monthly premium $____________

Portion for the child(ren) listed in section IV: $______________

3.

Other than children of this action listed in section IV, are other adults and/or child(ren) included in this plan? [ ] Yes [ ] No

(If yes, provide information below.)

Total number of adults: _____________________________

Total number of children: _____________________________

4.

If the petitioner does not have health care coverage or the coverage is through Medicaid, is employer-sponsored coverage

available for:

Self

[ ] Yes

[ ] No

Child(ren) listed in section IV

[ ] Yes

[ ] No

(If no, skip to C.)

5.

Based on the residence of the child(ren), is the petitioner’s employer-sponsored coverage accessible to the child(ren) in

section IV? [ ] Yes [ ] No [ ] Unknown (If no, skip to C.)

6.

How much would the premiums be for an insurance plan offered by the petitioner’s employer?

a. For self: $_____________ per _______________ (weekly, bi-weekly, semi-monthly, monthly, quarterly, yearly)

b. To add child(ren) in section IV: $____________ per ___________ (weekly, bi-weekly, semi-monthly, monthly, quarterly, yearly)

C.

Health Care Coverage for Respondent: Does the respondent have health care coverage? [ ] Yes [ ] No (If no, skip to C.4.)

[ ] Unknown (If unknown, skip to D.)

1.

Respondent’s health care coverage is provided by: [ ] Medicaid (Skip to C.4.) [ ] TRICARE (Skip to D.)

[ ] Indian Health Service (Skip to D.) [ ] Unknown (Skip to D.)

[ ] Self through his/her employer (Continue to C.2 below.)

[ ] Self through an individual policy (Continue to C.2 below.)

[ ] Other person: _________________________ Relationship to respondent: _______________ (Complete C.2 below.)

2.

Health care coverage provider name: ___________________________________________________________________

Address:

Policy ID number:

Group number:

Monthly premium $____________

Portion for the child(ren) in section IV: $______________

3.

Other than children listed in section IV, are other adults and/or child(ren) included in this plan? [ ] Yes [ ] No

(If yes, provide information below.)

Total number of adults: ____________________________

Total number of children: _____________________________

4.

If the respondent does not have health care coverage or the coverage is through Medicaid, is employer-sponsored coverage

available for:

Self

[ ] Yes

[ ] No

[ ] Unknown (If no or unknown, skip to question D.)

Children listed in section IV

[ ] Yes

[ ] No [ ] Unknown (If no or unknown, skip to question D.)

5.

Based on the residence of the child(ren), is the respondent’s employer-sponsored coverage accessible to the child(ren)

in section IV? [ ] Yes [ ] No [ ] Unknown (If no, skip to question D.)

GENERAL TESTIMONY, PAGE 7

V. Health Care Coverage (Continued):

6.

How much would the premiums be for an insurance plan offered by the respondent’s employer?

For self: $_____________ per _______________ (weekly, bi-weekly, semi-monthly, monthly, quarterly, yearly)

To add child(ren) in section IV: $___________ per __________ (weekly, bi-weekly, semi-monthly, monthly, quarterly, yearly)

D.

Do any of the children listed in section IV have special needs or extraordinary medical expenses not covered by

insurance? [ ] Yes [ ] No [ ] Unknown (If yes, provide additional information about the child(ren) involved, the type of

needs/medical expenses, and the related costs in section IX.)

E.

Is the petitioner asking to be reimbursed for medical expenses paid? [ ] Yes [ ] No (If yes, provide information below.)

Balance: $ _______________

as of

__________ (date) (Provide date, type of expense, and cost in section IX.)

F.

Is the petitioner asking to be compensated for ongoing medical expenses? [ ] Yes [ ] No (If yes, provide information below.)

Type of expense: ___________________

Amount: $ ________________

per

_____________ (frequency)

(Provide additional information about the child(ren) involved, the need for ongoing expenses, and the expenses in section IX.)

VI. Additional Information for Child Support Calculation:

[ ] See section IX

A.

Establishment (If no child support order exists, complete the following section.):

1. Does a custody/parenting time order exist?

[ ] Yes

[ ] No (If yes, complete the information below and attach a copy of the order.)

Issuing tribunal number: ________________ Date of order: ____________

2. If an order does not exist, is there a written custody/parenting time agreement? [ ] Yes [ ] No (If yes, attach a copy.)

3. In the past 12 months or since separation (whichever is shorter), how many overnights has the child(ren) stayed with

obligee ____________ obligor ____________?

4. Is child support sought for a period of time prior to the date of the petition for support (Uniform Support Petition)?

[ ] Yes [ ] No (If yes, complete the following questions and section VIII for the period of time.)

a.

Support is sought from the following date: ____________

b.

During the period of time for which retroactive support is being sought, did the child(ren) reside with the

obligor, other than the time specified under an existing custody/parenting time order?

[ ] Yes [ ] No (If yes, describe.) ____________________________________________________________________________________

____________________________________________________________________________________________

c.

During the period of time for which retroactive support is being sought, did the obligor make direct payments

to the obligee? [ ] Yes [ ] No (If yes, attach an affidavit of payments.)

d.

Was public assistance paid for any of the children listed in section IV?

[ ] Yes [ ] No (If yes, check the appropriate box and provide the period of benefit and the state.)

[ ] TANF

/

To

/

By:

First month

year

Last month

year

State

[ ] Medicaid

/

To

/

By:

First month

year

Last month

year

State

[ ] Foster Care

/

To

/

By:

First month

year

Last month

year

State

GENERAL TESTIMONY, PAGE 8

VI. Additional Information for Child Support Calculation (Continued):

B.

Modification (If a child support order exists that the petitioner seeks to modify, complete the following section.):

1. Indicate the basis for the modification petition (check all that apply):

The earnings of the obligor have:

[ ] substantially increased

[ ] substantially decreased

The earnings of the obligee have:

[ ] substantially increased

[ ] substantially decreased

The needs of the child(ren) have:

[ ] substantially increased

[ ] substantially decreased

[ ] The current support order was most recently established or modified at least 3 years ago or such lesser time as

permitted by the laws of the responding jurisdiction.

[ ] Other; explain: ________________________________________________________________________________

2. Does a custody/parenting time order exist?

[ ] Yes

[ ] No (If yes, attach a copy of the order.)

Issuing tribunal number_________________________________________________________ Date of order ___________________

3. If a custody/parenting time order does not exist, is there a written custody/parenting time agreement? [ ] Yes [ ] No

(If yes, attach a copy of the agreement.)

4. In the past 12 months or since separation (whichever is shorter), how many overnights has the child(ren) stayed with the

obligee ____________ obligor ____________?

VII. Support Order and Payment:

[ ] See section IX

A.

Is there an order for divorce or legal separation involving the children in this action?

[ ] Yes [ ] No (If yes, provide a copy of the order.)

B.

Does a current support order exist? [ ] Yes [ ] No (If yes, attach obligor’s support payment history.)

C.

Does the support order require the obligor to pay amounts to anyone other than to the State Disbursement Unit (SDU) (e.g.,

directly to the obligee, child care provider, or health care provider)?

[ ] Yes [ ] No (If yes, complete D.)

D.

Has the obligor made any direct payments under the order noted in C?

[ ] Yes [ ] No (If yes, attach an affidavit of payments.)

E.

If a support order does not exist, has the obligor made any voluntary support payments?

[ ] Yes [ ] No (If yes, attach an affidavit of payments.)

VIII. Financial Information:

[ ] See section IX

Information required varies based on responding jurisdiction’s support guidelines. Petitioner includes an obligee caretaker with legal custody of the child(ren).

.

Monthly income from all sources:

1.

Is the petitioner employed?

[ ]

Yes; occupation:

[ ]

No; income source:

GENERAL TESTIMONY, PAGE 9

VIII. Financial Information (Continued):

Monthly income from all sources (Continued):

2.

Gross monthly income amounts:

Petitioner

Public Assistance

Supplemental Security Income (SSI)

$

ii) TANF

$

iii) Other

$

Base pay salary, wages

$

Overtime, commission, tips, bonuses, part time

$

Unemployment compensation

$

Worker’s compensation

$

Social Security Disability (not SSI)

$

Social Security Retirement

$

Dividends and interest

$

Trust/annuity income

$

Pensions, retirement

$

Child support

$

Spousal support/alimony

$

Income producing assets

$

All other sources (specify)

$

3.

Deductions from gross pay:

Federal income tax

$

State income tax

$

Local tax

$

FICA

$

4.

Other deductions:

Mandatory retirement

$

Nonmandatory retirement

$

Medical insurance

$

Union dues

$

Other (specify)

$

5.

Gross income prior year:

$

IX. Other Pertinent Information:

[ ] Continued on attached sheet(s), incorporated by reference.

GENERAL TESTIMONY, PAGE 10

X. Attached and Incorporated by Reference:

[ ]

Required number of copies of all support orders for the case

[ ]

Certified child support payment records

[ ]

Arrears balance and/or accrued Interest (affidavit of arrears)

[ ]

Payment history

[ ]

Copies of three most recent pay stubs from current employer(s)

[ ]

Copies of unreimbursed medical bills for the child(ren) in this action

[ ]

Copy of most recent federal tax return

[ ]

Declaration in Support of Establishing Parentage for each child whose parentage is at issue

[ ]

Copy of child(ren)’s birth certificate(s)/record(s)

[ ]

Acknowledgment of parentage

[ ]

Documentation of legal custody/guardianship of child(ren)

[ ]

Documentation of child care expenses

[ ]

Documentation of ongoing medical expenses for the child(ren) in this action

[ ]

Documentation in support of request for modification

[ ]

Copy of order for divorce or legal separation involving the child(ren) in this action

[ ]

Other:

[ ] Additional attached document(s), incorporated by reference.

XI. Declaration:

Under penalty of perjury, all information and facts stated in this General Testimony are true to the best of my knowledge, information, and belief.

Date

Petitioner (Name)

Signature

or

Date

Name/Title, Agency or Tribunal Representative

Signature

Encryption Requirements:

When communicating this form through electronic transmission, precautions must be taken to ensure the security of the data. Child support agencies are encouraged to use the electronic applications provided by the federal Office of Child Support Enforcement. Other electronic means, such as encrypted attachments to e-mails may be used if the encryption method is compliant with Federal Information Processing Standard (FIPS) Publication 140-2 (FIPS PUB 140-2).

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