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

Non-IV-D Case:

[
[
[
[
[

]
]
]
]
]

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

File Stamp

[ ]

Responding IV-D Case Identifier
Responding Tribunal Number
Initiating IV-D Case Identifier
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

[ ] Confirmed _____________ (date)

9. Employer 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 and location)

B. Physical Description of Child (ren)’s Mother (Attach photo if available.)
1. Race
C.

2. Height

3. Weight

4. Hair Color

5. Eye Color

Present Martial 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: 01/31/2014

Page 1 of 10

Initiating IV-D Case Identifier

GENERAL TESTIMONY, PAGE 2
D. Information about Current Spouse of Partner of Child (ren)’s Mother
1. Name of Current Spouse or Partner (first, middle, last)

2. Is Current Spouse/Partner Employed?
[ ] 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 children (ren)’s mother responsible for dependents other than those listed in Section V (pages 4 & 5)?
[ ] Yes
1.

2.

3.

[ ] No

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

a. Full Name (first, middle, last)

b. Date of Birth

c. Relationship

d. Living With:

e. Source of Support/Income

f. Monthly Amount; Gross:

a. Full Name (first, middle, last)

b. Date of Birth

c. Relationship

d. Living With:

e. Source of Support/Income

f. Monthly Amount; Gross:

a. Full Name (first, middle, last)
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

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

[ ] Confirmed _____________ (date)

9. Employer 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 and location)

B. Physical Description of Child (ren)’s Father (Attach photo if available.)
1. Race

General Testimony

2. Height

3. Weight

4. Hair Color

5. Eye Color

Page 2 of 10

Initiating IV-D Case Identifier

GENERAL TESTIMONY, PAGE 3
C.

Present Martial 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 of Partner of Child (ren)’s Father
1. Name of Current Spouse or Partner (first, middle, last)

2. Is Current Spouse/Partner Employed?
[ ] 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 children (ren)’s father responsible for dependents other than those listed in Section V (pages 4 & 5)?
[ ] Yes
1.

2.

3.

[ ] No

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

a. Full Name (first, middle, last)

b. Date of Birth

c. Relationship

d. Living With:

e. Source of Support/Income

f. Monthly Amount; Gross:

a. Full Name (first, middle, last)

b. Date of Birth

c. Relationship

d. Living With:

e. Source of Support/Income

f. Monthly Amount; Gross:

a. Full Name (first, middle, last)

Net:

b. Date of Birth

c. Relationship

d. Living With:

e. Source of Support/Income

f. Monthly Amount; Gross:

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

Net:

Net:
[ ] See Section X

2. [ ] Nondisclosure Finding Attached

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

[ ] Confirmed _____________ (date)

5. Social Security Number
8. Home Phone
(
)

10. Employer Name & Address [ ] Confirmed ________(date)

6. Date of Birth

7. Sex

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

Initiating IV-D Case Identifier

GENERAL TESTIMONY, PAGE 4
IV. Legal Relationship of Parents
1.

[ ] See Section X

[ ] Never married to each other

2. [ ] Married on

in
Date

3.

[ ] Married by common law for the period

4.

[ ] Separated on

6.

[ ] Legally separated on

County/State

in
Dates

Date

in
Date

County/State

in
Date

7.

County/State

5. [ ] Divorced on

[ ] Divorce pending in

County/State

8. [ ] Support Order Entered on
County/State

9.

[ ] No support order

11.

Tribunal & Location (Divorce Legal Separation, Support Order):

Date

10. [ ] Other

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.

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

a. Full Legal Name (first, middle, last)
b. Address

2.

c. Social Security Number

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

d. Sex

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

e. Date of Birth

a. Full Legal Name (first, middle, last)
b. Address

3.

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

e. Date of Birth

a. Full Legal Name (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

Initiating IV-D Case Identifier

GENERAL TESTIMONY, PAGE 5

4.

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

a. Full Legal Name (first, middle, last)
b. Address

c. Social Security Number

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

d. Sex

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

e. Date of Birth

B. The child(ren) began residing in

on

.

State

VI. Medical Insurance

Month/Year

[ ] See Section X

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 oblige is provided by:

For dependent
child(ren)
Obligee
Obligor

[ ]
[ ]

State Medicaid

[ ]

Obligee’s Employer
Obligor’s Employer

[ ]
[ ]

Other

[ ]

For obligee

Obligee’s Insurance Company:

[ ]
[ ]
[ ]

Policy Number:
Obligor’s Insurance Company:

[ ]
[ ]
[ ]

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

7.

[ ] No

[ ] Unknown

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?

General Testimony

[ ] Yes

[ ] No

[ ] Unknown

Page 5 of 10

Initiating IV-D Case Identifier

GENERAL TESTIMONY, PAGE 6
VII. Support Order and Payment Information

[ ] See Section X

1.

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

2.

Did child(ren) reside with the obligor at anytime during the period for which support is sought, except during

[ ] Yes

periods of visitation specified by a tribunal’s order?

[ ] Yes

[ ] No

If “Yes”, Identify Period of Residency

[ ] No

From:

3.

4.

Thru:

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

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 $

Per Month/Week/etc.

as of

(date)

Toward Arrears
$

Total Arrears $

Per Month/Week/etc.

as of

(date)

Tribunal’s Name & Address
Date of Order

Current Amount
$

Unpaid Interest $

Per Month/Week/etc.

as of

(date)

Toward Arrears
$

Total Arrears $

Per Month/Week/etc.

as of

(date)

Tribunal’s Name & Address
Date of Order
Unpaid Interest $

Current Amount
$
as of

Per Month/Week/etc.
(date)

Toward Arrears
$
Total Arrears $
as of

Per Month/Week/etc.
(date)

Tribunal’s Name & Address
5.

Unpaid Medical Cost Reimbursement

$

as of

(attach documentation)
6.

Date

Other Unpaid Costs and Fees

$

as of
Date

Explain:
7.

Direct Payments to Obligee:

8.

Obligor’s support payment history:

[ ]

Certified copy of tribunal/agency payment
history is attached. (Skip to page 7)

From (Year) to (Year):

General Testimony

[ ]

Affidavit from Obligee Attached

[ ]

[ ]

Payment history provided on page 6a.

No Direct Payments Received

[ ]

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 Identifier

Adjudicated Arrears

$

as of
Date of Order

Year:
Amount Due

Year:
Amount Paid

Balance

Amount Due

Amount Paid

Balance

Amount Paid

Balance

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

Year:
Amount Paid

Balance

Amount Due

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

$

as of

Date

Name/Title, Agency or Tribunal

Signature

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

Notary Public Official and Title

Commission Expires

General Testimony

Page 6a of 10

Initiating IV-D Case Identifier

GENERAL TESTIMONY, PAGE 7
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:

First month

2.

/

year

Last month

Total amount of TANF/Foster Care paid:

by:
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?

2.

Gross Monthly Income Amounts:

[ ]

a) Public Assistance
i) SSI

Yes; occupation:
Petitioner

[ ]

No; income source:

Current Spouse/Partner

Obligor’s Dependent(s)

$

$

$

ii) Family Assistance

$

$

$

iii) Other

$

$

$

$

$

$

d) Unemployment compensation

$
$

$
$

$
$

e) Worker’s compensation

$

$

$

b) Base pay salary, wages
c) Overtime, commission,
tips, bonuses, part time

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

Initiating IV-D Case Identifier

GENERAL TESTIMONY, PAGE 8
Petitioner
5.

Adjusted Net Monthly

Current Spouse/Partner

Obligor’s Dependent(s)

$

$

$

a) Savings

$

$

$

b) Loan Repayment

$

$

$

c) Mandatory Retirement

$

$

$

d) Non-mandatory Retirement

$

$

$

e) Medical Insurance

$

$

$

f) Union Dues

$

$

$

g) Other (specify)

$

$

$

(lines 5 minus lines “6a through 6g”)

$

$

$

Gross Income Prior Year

$

$

$

(lines “3” minus lines “4a through 4d”)
6.

7.

8.

Other Deductions

Net Monthly Income

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

B. Monthly Expenses:
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)
12)
13)
14)
15)
16)
17)
18)
19)

Rent/Mortgage
Homeowners/Renters Insurance
Home Maintenance & Repair
Heat
Electricity/Gas
Telephone
Water/Sewer
Food
Laundry/Cleaning
Clothing
Life Insurance
Medical Insurance
Uninsured Extraordinary Medical
(attach documentation)
Other Uninsured Health-Related Expenses
Auto Payment
Auto Insurance
Auto Expenses
Other Transportation
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

Petitioner

Obligor’s Dependents

$
$
$
$
$
$
$
$
$
$
$
$

$
$
$
$
$
$
$
$
$
$
$
$

$
$
$
$
$
$
$

$
$
$
$
$
$
$

$
$
$

$
$
$

$

$

Page 8 of 10

Initiating IV-D Case Identifier

GENERAL TESTIMONY, PAGE 9

C. Assets:
1) Real Estate
Address

Owner(s)

Title

$

minus

$

=

Assessed Value

2)

$

Mortgage(s)

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
$
Make

Model

Year

minus $
Estimated Value

$
Make

Model

Year

7)

Model

Year

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

General Testimony

Loan Balance
minus $

Estimated Value

$
Make

= $

= $
Loan Balance

minus $
Estimated Value

Describe:

= $
Loan Balance

$
$

Page 9 of 10

Initiating IV-D Case Identifier

GENERAL TESTIMONY, PAGE 10

(Attach additional sheets if necessary).

X. Other Pertinent Information

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

Petitioner (Name/Title)

Signature

Date

Agency Representative (Name/Title)

Signature

Sworn to and Signed Before me
This Date County/State

Notary Public, Tribunal/Agency
Official and Title

Commission Expires

General Testimony

Page 10 of 10