General Testimony {UIFSA-5}

GENERAL TESTIMONY (Instructions should be provided to the petitioner as part of the form.) THIS FORM CONTAINS SENSITIVE INFORMATION 226 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 247 311 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 Responding Tribunal Number: NOTE: Initiating IV - D Case Identifier : [ ] Nondisclosure Finding/Affidavit attached Initiating Tribunal Number: [ ] This form sent through EDE I, , declare under penalty of perjury: Legal Name (firstI. 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 n (first, middle, last, suffix): b.Year of birth: c.Relationship:d.Living with: General Testimony OMB 0970 226 0085 Expiration Date: Page 1 of 10 American LegalNet, Inc. www.FormsWorkFlow.com 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. a. Child(ren) name(s): b. Amount:c. Frequency: d. State and county/tribe/country:e. Tribunal number: 2. a. Child(ren) name(s): b. Amount:c. Frequency: d. State and county/tribe/country:e. Tribunal number: 3. a.Child(ren) name(s): b. Amount:c. Frequency: d. State and county/tribe/country:e. 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 2 of 10 American LegalNet, Inc. www.FormsWorkFlow.com 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. a. Child(ren) name(s): b. Amount: $ c. Frequency: d. State and county/tribe/country: e. Tribunal number: 2. a. Child(ren) name(s): b. Amount: $ c. Frequency: d. State and county/tribe/country: e. Tribunal number: 3. a. Child(ren) name(s): b. Amount: $ c. Frequency: d. State and county/tribe/country: e. Tribunal number I II . Legal Relationship of P arents of Children L isted 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 4. Support order established? 5. Living with petitioner? $ [ ] Yes [ ] No [ ] Yes [ ] No 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 3 of 10 American LegalNet, Inc. www.FormsWorkFlow.com 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 4. Support order established? 5. Living with petitioner? $ [ ] Yes [ ] No [ ] Yes [ ] No 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 4. Support order established? 5. Living with petitioner? $ [ ] Yes [ ] No [ ] Yes [ ] No 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. Child222s 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