Petition (Generic) {NHJB-2277-FS}

THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) PETITION FOR 1. Petitioner Name Date of Birth Residence Address Mailing Address (if different) Telephone Number (Home) 2. Respondent Name Date of Birth Residence Address Mailing Address (if different) Telephone Number (Home) (Work) E-mail address (Work) E-mail address If this petition will affect minor children, complete #3, 4, and 5 below, otherwise move to #6. 3. List any minor children to be affected by this petition: Name Date of Birth Name Date of Birth 4. Please check one of the following regarding public assistance. No public assistance (TANF) is now being or has within the last 6 months been provided, nor is medical assistance (Medicaid) presently being provided, for any minor child listed above. The N.H. Department of Health and Human Services is providing or has provided within the last 6 months public assistance (TANF) and/or medical assistance (Medicaid) for a minor child or children listed above. If you check this box, you must mail copies of this petition and the personal data sheet to DHHS at: New Hampshire Department of Health and Human Services Division of Child Support Services - Legal Unit 129 Pleasant Street Concord, NH 03301 NHJB-2277-FS (12/15/2006) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: PETITION FOR 5. Are there any pending adoption, juvenile, domestic violence, domestic relations, paternity, legitimation, custody, parental rights and responsibilities, or other proceedings in any court in any state affecting any child(ren) named in this petition or parents of those children? Yes No If yes, specify 6. What orders do you want the court to make? Date Signature of Petitioner (Sign in front of Notarial Officer) Attorney (if any) Attorney's Address State of This instrument was acknowledged before me on My Commission Expires Affix Seal, if any , County of by Signature of Notarial Officer / Title NHJB-2277-FS (12/15/2006) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com