Form 1 General Testimony

GENERAL TESTIMONY
Petitioner: Name (first, middle, last)
Social Security Number

IV-D Case: [
[
[
[
[

Respondent: Name (first, middle, last)
Social Security Number

] TANF
] IV-E Foster Care
] Medicaid Only
] Former Assistance
] Never Assistance

File Stamp

Non-IV-D Case: [ ]
Responding IV-D Case Number
Responding Tribunal Number

Initiating IV-D Case Number
Initiating Tribunal Number

Petitioner is:

Respondent is:

[ ] Obligee

[ ] Caretaker Other than Parent

[ ] Obligor

[ ] Foster Care

[ ] Obligee

[ ] Caretaker Other than Parent

[ ] Obligor

[ ] Foster Care

____________________________________________ being duly sworn, under penalties of perjury, testifies as follows:
Name (first, middle, last)

I. Personal Information About Child(ren)'s Mother
A.1. Mother is:

[ ] Obligee

[ ] Obligor

[ ] See Section X
2.

[ ] Nondisclosure Finding Attached

3. Full Name (first, middle, last)
Nickname, alias, maiden name, former married name, etc.
4. Home Address

9. Employer

[ ]

Confirmed______________(date)

Name & Address

[ ] Confirmed_________(date)

5. Social Security Number

6. Date of Birth

7. Home Phone
(
)

8. Work Phone
(
)

10(a). Occupation, Trade or Profession

10(b). Highest Level Of Education Attained

11. Estimated Gross Monthly Earnings
$

12. Other Monthly Income (& source)
$

13. Real or Personal Property (type & location)

B. Physical Description of Child(ren)'s Mother (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
1.

[ ] Married

2.

[ ] Single

3.

[ ] Living with Non-Marital Partner

4.

[ ] Divorced

5.

[ ] Legally Separated

6.

[ ] Separated

General Testimony

7.

[ ] Unknown

OMB 0970 - 0085 Expiration Date: 01/31/2008

Page 1 of 10

GENERAL TESTIMONY, PAGE 2

Initiating IV-D Case Number

D. Information about Current Spouse or Partner of Child(ren)'s Mother
1. Name of Current Spouse or Partner

2. Is Current Spouse/Partner Employed?

(first, middle, last)

[ ] Yes
3. Name and Address of Spouse's/Partner's Employer

[ ] No

[ ] 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
1.

2.

3.

[ ] No

a. Full Name

[ ] Unknown (If yes, provide information below.)
b. Date of Birth

(first, middle, last)

c. Relationship

d. Living With:

e. Source of Support/Income

f. Monthly Amount; Gross:

a. Full Name

b. Date of Birth

(first, middle, last)

c. Relationship

d. Living With:

e. Source of Support/Income

f. Monthly Amount; Gross:

a. Full Name

d. Living With:

e. Source of Support/Income

f. Monthly Amount; Gross:

II. Personal Information About Child(ren)'s Father
[ ] Obligee

Net:

b. Date of Birth

(first, middle, last)

c. Relationship

A.1. Father is:

Net:

[ ] Obligor

Net:
[ ] See Section X

2.

[ ] Nondisclosure Finding Attached

3. Full Name (first, middle, last)
Nickname, Alias
4. Home Address

9. Employer

[ ]

Confirmed______________(date)

Name & Address

[ ] Confirmed_________(date)

5. Social Security Number

6. Date of Birth

7. Home Phone
(
)

8. Work Phone
(
)

10(a). Occupation, Trade or Profession

10(b). Highest Level Of Education Attained

11. Estimated Gross Monthly Earnings
$

12. Other Monthly Income (& source)
$

13. Real or Personal Property (type & location)

B. Physical Description of Child(ren)'s Father (Attach photo if available.)
1. R ace
General Testimony

2. Height

3. Weight

4. Hair Color

5. Eye Color
Page 2 of 10

GENERAL TESTIMONY, PAGE 3

Initiating IV-D Case Number

C. Present Marital Status of Child(ren)'s Father
1.

[ ] Married

2.

[ ] Single

3.

[ ] Living with Non-Marital Partner

4.

[ ] Divorced

5.

[ ] Legally Separated

6.

[ ] Separated

7.

[ ] Unknown

D. Information about Current Spouse or Partner of Child(ren)'s Father
1. Name of Current Spouse or Partner

2. Is Current Spouse/Partner Employed?

(first, middle, last)

[ ] Yes
3. Name and Address of Spouse's/Partner's Employer

[ ] No

[ ] 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 (If yes, provide information below.)
1.

2.

3.

a. Full Name

b. Date of Birth

(first, middle, last)

c. Relationship

d. Living With:

e. Source of Support/Income

f. Monthly Amount; Gross:

a. Full Name

b. Date of Birth

(first, middle, last)

c. Relationship

d. Living With:

e. Source of Support/Income

f. Monthly Amount; Gross:

a. Full Name

Net:

Net:

b. Date of Birth

(first, middle, last)

c. Relationship

d. Living With:

e. Source of Support/Income

f. Monthly Amount; Gross:

Net:

III. Personal Information About Caretaker Other than Parent
1. Caretaker's Relation to Child is:
[ ] Has legal custody/guardianship of child

2.

[ ] See Section X

[ ] Nondisclosure Finding Attached

3. Full Name (first, middle, last)
Nickname, alias, maiden name, former married name, etc.
4. Home Address

10. Employer

[ ]

Confirmed____________(date)

Name & Address

[ ] Confirmed_______(date)

5. Social Security Number

6. Date of Birth

8. Home Phone
(
)

9. Work Phone
(
)

11(a). Occupation, Trade or Profession

11(b). Highest Level Of Education Attained
12. Estimated Gross Monthly Earnings
$

13. Other Monthly Income (& source)
$

14. Date Child(ren) Began Residing With Caretaker
General Testimony

Page 3 of 10

7. Sex

GENERAL TESTIMONY, PAGE 4

Initiating IV-D Case Number

IV. Legal Relationship of Parents
1. [ ] Never married to each other

[ ] See Section X

2. [ ] Married on _______________________in ____________________________
Date

County/State

3. [ ] Married by common law for the period __________________________in__________________________________
Dates

4. [ ] Separated on _______________

County/State

5. [ ] Divorced on ________________in_____________________________

Date

Date

County/State

6. [ ] Legally separated on___________________in________________________________
Date

County/State

7. [ ] Divorce pending in_____________________________ 8. [ ] Support Order Entered on____________________
County/State

Date

9. [ No support order
10. [ ] Other_____________________________________________________
]
__
11. Tribunal & Location (Divorce, Legal Separation, Support Order):

V. Dependent Child(ren) in this Action

[ ] See Section X

A. List obligor's (named on page 1 of this form) child(ren) only.

[ ] Nondisclosure Finding Attached

1. a. Full Legal Name
b. Address

f. Paternity Established?
[ ] Yes (check how) [ ] No
[ ] By order
[ ] By voluntary acknowledgment
[ ] By adoption
[ ] By conclusive marital presumption
[ ] Other:

c. Social Security Number

g. Support Order Established?
[ ] Yes
[ ] No

d. Sex

h. Living with Petitioner?
[ ] Yes
[ ] No

2. a. Full Legal Name

(first, middle, last)

e. Date of Birth

(first, middle, last)

b. Address

f. Paternity Established?
[ ] Yes (check how) [ ] No
[ ] By order
[ ] By voluntary acknowledgment
[ ] By adoption
[ ] By conclusive marital presumption
[ ] Other:

c. Social Security Number

g. Support Order Established?
[ ] Yes
[ ] No

d. Sex

h. Living with Petitioner?
[ ] Yes
[ ] No

3. a. Full Legal Name

e. Date of Birth

(first, middle, last)

b. Address

f. Paternity Established?
[ ] Yes (check how) [ ] No
[ ] By order
[ ] By voluntary acknowledgment
[ ] By adoption
[ ] By conclusive marital presumption
[ ] Other:

c. Social Security Number

g. Support Order Established?
[ ] Yes
[ ] No

d. Sex

h. Living with Petitioner?
[ ] Yes
[ ] No

General Testimony

e. Date of Birth

Page 4 of 10

GENERAL TESTIMONY, PAGE 5
4.

Initiating IV-D Case Number

b. Address

f. Paternity Established?
[ ] Yes (check how) [ ] No
[ ] By order
[ ] By voluntary acknowledgment
[ ] By adoption
[ ] By conclusive marital presumption
[ ] Other:

c. Social Security Number

g. Support Order Established?
[ ] Yes
[ ] No

d. Sex

h. Living with Petitioner?
[ ] Yes
[ ] No

a. Full Legal Name

(first, middle, last)

e. Date of Birth

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

Month/Year

[ ] See Section X

VI. Medical Insurance

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

[ ] Yes

[ ] No

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

[ ] Yes

[ ] No

3. Medical coverage for dependent child(ren) listed in Section V and/or the obligee is provided by:
For dependent
child(ren)

For obligee

Obligee

[ ]

[ ]

Obligor

[ ]

[ ]

State Medicaid

[ ]

[ ]

Obligee's Insurance Company:
Policy Number:
Obligor's Insurance Company:

Obligee's Employer

[ ]

[ ]

Obligor's Employer

[ ]

[ ]

Other _________________

[ ]

[ ]

Policy Number:
Other Insurance Company:

Unknown

[ ]

[ ]

No Coverage

[ ]

[ ]

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.)

8. Is the obligee asking to be reimbursed for medical coverage by obligor? [ ] Yes

General Testimony

[ ] No

[ ] Unknown

Page 5 of 10

GENERAL TESTIMONY, PAGE 6

Initiating IV-D Case Number

VII. Support Order and Payment Information

[ ] See Section X
[ ] Yes

1. Does a support order exist? (If "No", skip to page 7.)

[ ] No

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

Current Amount
$

Unpaid Interest $

as of

Per Month/Week/etc.
(date)

Toward Arrears
$

Total Arrears $

Per Month/Week/etc.

as of

(date)

Tribunal's Name & Address
Date of Order

Current Amount
$

Unpaid Interest $

as of

Per Month/Week/etc.
(date)

Toward Arrears
$

Total Arrears $

Per Month/Week/etc.

as of

(date)

Tribunal's Name & Address
Date of Order

Current Amount
$

Unpaid Interest $

as of

Per Month/Week/etc.
(date)

Toward Arrears
$

Total Arrears $

Per Month/Week/etc.

as of

(date)

Tribunal's Name & Address
5. Unpaid Medical Cost Reimbursement
(attach documentation)

$____________________

6. Other Unpaid Costs and Fees

$____________________

as of _________________________
Date

as of _________________________
Date

Explain: ______________________________________________________________________________________________
7. Direct Payments to Obligee:

[ ] Affidavit from Obligee Attached

[ ] No Direct Payments Received

8. Obligor's support payment history:

[ ] Certified copy of tribunal/agency payment

[ ] Payment history provided on page 6a.

history is attached. (Skip to page 7).

From (Year) to (Year):

General Testimony

[ ] N.A.; responding State does not require.
(Skip to page 7).

Agency Which Prepared Audit/Payment History:

Page 6 of 10

GENERAL TESTIMONY, PAGE 6a
Obligor's Payment History

Initiating IV-D Case Number
Adjudicated Arrears $____________________ as of ____________________
Date of Order

Year: ______________________
Amount Due

Amount Paid

Balance

Year: ______________________
Amount Due

Amount Paid

Balance

Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Total
Year: ______________________
Amount Due

Amount Paid

Balance

Year: ______________________
Amount Due

Amount Paid

Balance

Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Total
Total of Adjudicated and Accrued Arrears $_____________________ as of ___________________________

________________________
Date

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

General Testimony

__________________________________________
____________________________________
Name/Title, Agency or Tribunal

Signature

__________________________________________
____________________________________
Notary Public Official and Title

Commission Expires

Page 6a of 10

GENERAL TESTIMONY, PAGE 7

Initiating IV-D Case Number

VIII. TANF / Foster Care/Medical Assistance Status

[ ] See Section X

[If no TANF/Foster Care/Medical Assistance benefits were paid, skip to Section IX.]
1. Period during which TANF/Foster Care was paid:
From:_______________/__________ To:_______________/__________by:____________________________
First month

year

Last month

2. Total amount of TANF/Foster Care paid:

year

State

$______________________ 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

[ ] See Section X

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

A. Monthly Income from All Sources:
1. Is the petitioner employed?

[ ] Yes; occupation:___________________ [ ] No; income source:_________________

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, part time

Petitioner

Current Spouse/Partner

Obligor's Dependent(s)

$_______________
$_______________
$_______________
$_______________

$________________
$________________
$________________
$________________

$________________
$________________
$________________
$________________

$_______________

$________________

$________________

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

$_______________

$________________

$________________

k) Child support

$_______________

$________________

$________________

l) Spousal support/alimony

$_______________

$________________

$________________

$_______________

$________________

$________________

m) All other sources

Explain "other sources":____________________________________________________________________
3. Total Gross Monthly
(lines "2a" through "2m")
4. Deductions From Gross
a) Federal Income Tax
b) State Income Tax
c) Local Tax
d) F.I.C.A.

General Testimony

$_______________

$________________

$________________

$_______________
$_______________
$_______________
$_______________

$________________
$________________
$________________
$________________

$________________
$________________
$________________
$________________

Page 7 of 10

GENERAL TESTIMONY, PAGE 8

Initiating IV-D Case Number
Petitioner

5. Adjusted Net Monthly

Current Spouse/Partner Obligor's Dependent(s)

$_______________

$________________

$________________

a) Savings

$_______________

$________________

$________________

b) Loan Repayment

$_______________

$________________

$________________

c) Mandatory Retirement

$_______________

$________________

$________________

d) Non-mandatory Retirement

$_______________

$________________

$________________

(lines "3" minus lines "4a through 4d")
6. Other Deductions

e) Medical Insurance

$_______________

$________________

$________________

f) Union Dues

$_______________

$________________

$________________

g) Other (specify)

$_______________

$________________

$________________

7. Net Monthly Income
(line 5 minus lines "6a through 6g")

$________________

$________________

$_________________

8. Gross Income Prior Year

$________________

$________________

$________________

Attach three most recent pay stubs from each current employer for all parties shown.

B. Monthly Expenses

Petitioner

Obligor’s Dependents

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_____________
Per ________
20) Support Payments, actual amount paid
21) Internet service
22) Other; Explain

$__________
$__________
$__________

$__________
$__________
$__________

Total Monthly Expenses (lines 1 through 22)

$__________

$__________

General Testimony

Page 8 of 10

GENERAL TESTIMONY, PAGE 9

Initiating IV-D Case Number

C. Assets:
1) Real Estate

____________________________________________________________________
Address

____________________________________________________________________
Ow ner(s)

____________________________________________________________________
Title

$__________________________

minus

$_________________________ =

Assessed Value

$_________________

Mortgage(s)

2) IRA, Keogh, Pension, Profit Sharing, Other Retirement Plans
_______________________________________________________________________________
$_________________
Institution or Plan Name and Account Number

_______________________________________________________________________________
$_________________
Institution or Plan Name and Account Number

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

7) Other (e.g., Personal Property, Securities, etc).
Total Assets (lines 1 through 7)

General Testimony

Estimated Value

Loan Balance

Describe: __________________

$_____________
$_____________

Page 9 of 10

GENERAL TESTIMONY, PAGE 10

Initiating IV-D Case Number

X. Other Pertinent Information

(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 pay stubs 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.
[ ] Documentation of legal custody/guardianship of child(ren).
[ ] Documentation that children are in foster care.
[ ] Other:________________________________________________________________________________________

All of the information and facts contained in this General Testimony are true and correct to my/our best knowledge
and belief.
______________________
Date

______________________
Date

______________________
Sworn to and Signed Before me
This Date County/State

General Testimony

_________________________________________
Petitioner (Name/Title)

_________________________________________
Agency Representative (Name/Title)

_________________________________________
Notary Public, Tribunal/Agency
Official and Title

_____________________________
Signature

_____________________________
Signature

_____________________________
Commission Expires

Page 10 of 10