Uniform Support Petition {UIFSA-4}

[ ] UNIFORM SUPPORT PETITION File Stamp 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. Petitioner: Legal Name (first, middle, last , suffix ) IV - D Case: [ ] TANF [ ] Obligee [ ] Obligor [ ] IV-E Foster Care Tribal Affiliation (if applicable) [ ] Medicaid Only [ ] Former Assistance Respondent: Legal Name (first, middle, last, suffix) [ ] Never Assistance Non - IV - D Case: [ ] [] Obligee Obligor Tribal Affiliation (if applicable) Responding IV - D Case Identifier : : Note: [ ] Non disclosure Finding/Affidavit attached Initiating IV - D Case Identifier : [ ] 003 This f orm s ent t hrough EDE Initiating Tribunal Number: The respondent in this action and/or the respondent222s property is subject to the jurisdiction of the responding tribunal. The legal name(s) of the child(ren) (first, middle, last, suffix) involved in this action is (are): Section I. Action: The petitioner in this action files this petition to request [ ] Establishment of parentage002 [ ] Establishment of an order for:002 [ ] Current child support, including medical support002 [ ] Retroactive child support since (date) [ ] Medical support only002 [ ] Spousal support (Non-IV-D only) [ ] Costs and fees002 [ ] Modification of a support order002 [ ] Other remedy sought: 002 Section II. Grounds Supporting the Remedy Sought in Section I : [ ] 003Parentage of the child(ren) named in this petition has not been established. (Attach a Declaration in Support of EstablishingParentage for each child.)002 [ ] The parents have a duty to support the child(ren) named in this petition. (If retroactive support is sought, check the applicable box below.) [ ] Respondent [ ] Petitioner has not provided support since: (date). [ ] It has been 3 years (or the time frame permitted by the laws of the responding jurisdiction) since the last review or modification.002 [ ] There has been a change in circumstances since the order was entered. (Explain.): 002 [ ]003 Additional grounds: Uniform Support Petition003 OMB 0970 226 0085 Expiration Date: Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com UNIFORM SUPPORT PETITION, PAGE 2002 Section III. Servicemembers Civil Relief Act: As of the current date: (Check one of the following.) [ ] The respondent is in military service. [ ] The respondent is not in military service. [ ] I am unable to determine whether the respondent is in military service. The following facts support the statement regarding whether or not the respondent is in military service: (Be specific.) Did you use the Servicemembers Civil Relief Act website to determine the respondent222s military status? [ ] Yes [ ] No (If yes, attach the results.) Section IV . Other Pertinent Information : The following documents are attached to and incorporated in this Petition: [ ] Petitioner222s General Testimony [ ] Declaration in Support of Establishing Parentage [ ] Acknowledgment of parentage [ ] Birth certificate/record of the child [ ] Documentation regarding military service [ ] Other: Section V. Declaration : Under penalty of perjury, all information and facts stated in this Uniform Support Petition are true to the best of my knowledge and belief. Date Printed name [ ] Signature of petitioner [ ] Signature of IV-D representative/title Date Printed name of petitioner222s private attorney and Signature of petitioner222s private attorney attorney/bar number (if applicable) 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). Uniform Support Petition Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR UNIFORM SUPPORT PETITION PURPOSE OF THE FORM: The Uniform Support Petition is a legal pleading needed to initiate an action in the responding tribunal. Its purposes are to assert that the tribunal has jurisdiction, to show enough facts to notify the respondent of the claim being made, and to provide the petitioner with a means to request specific action or relief. The petitioner can provide additional information in the accompanying affidavits and other attachments. 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. The Personal Information Form for UIFSA 247 311 must be attached. HEADING/CAPTION: 225 Identify the petitioner and respondent by full legal name (first, middle, last, suffix) and, if applicable, include the name of the tribe with which the petitioner or respondent is affiliated. 225 Identify if the petitioner is the obligee or the obligor. This will clarify who is submitting the petition. 225 Note that a Personal Information Form for UIFSA 247 311 must be attached. 225 Check the appropriate box to identify the type of case: TANF, IV-E foster care, Medicaid only, former assistance, never assistance, or non-IV-D. 225 In the appropriate spaces, if applicable and known, enter the responding jurisdiction222s IV-D case identifier and tribunal number. Italicized text that appears within a 223box224 refers to policy or provides additional information. TANF means the obligee222s family is currently receiving IV-A cash payments. A Medicaid only case is a case in which the obligee222s family receives Medicaid but does not receive TANF. A former assistance case might be a case for state arrears only or for a family that previously received TANF, but is not doing so at this time. The responding jurisdiction is the jurisdiction that is working the case at the request of the initiating jurisdiction. Under 223IV-D case identifier,224 enter the number/identifier identical to the one submitted on the Federal Case Registry, which is a left-justified up to 15-character alphanumeric field, allowing all characters except asterisk and backslash, and with all characters in uppercase. Under 223tribunal number,224 you may enter the docket number, cause number, or any other appropriate reference number that the responding tribunal may use to identify the case, if known. For a n address outside the United States , be sure to include the foreign country and postal code . Tribal IV-D programs may choose to use the federal Intergovernmental forms. However, they are not required to use or accept such forms. If you have any questions, contact the tribal IV-D agency directly using the contact information on the OCSE website. Where forms request a locator code, note that tribal locator codes uniquely identify tribal cases with 2239224 in the first position, 0 (zero) in the second position, and then a 3-character tribal code defined by the Bureau of Indian Affairs (BIA). 225 In the appropriate spaces, enter the initiating jurisdiction222s IV-D case identifier, and, if applicable, tribunal number. The initiating jurisdiction is the jurisdiction that referred the case to the responding jurisdiction for services. Under 223IV-D case identifier,224 enter the number/identifier identical to the one submitted on the Federal Case Registry, which is a left-justified up to 15-character alphanumeric field, allowing all characters except asterisk and backslash, and with all characters in uppercase. Under 223tribunal number,224 you may enter the docket number, cause number, or any other appropriate reference number that the initiating tribunal has assigned to the case. Uniform Support Petition Instructions Page 1 of 4002 American LegalNet, Inc. www.FormsWorkFlow.com In the 223NOTE:224 section, check any of the following that apply: 225 Nondisclosure Finding/Affidavit attached -If there is a finding prohibiting disclosure of a party222s or child(ren)222s address/identifying information or an aff