General Testimony

INSTRUCTIONS FOR GENERAL TESTIMONY
PURPOSE OF THE FORM:
The General Testimony provides a framework for stating the detailed information and evidence necessary to support the action
requested in the Uniform Support Petition. The sections in the General Testimony may or may not apply to all cases. Before
completing the form, carefully consider the status of the individual petitioner completing the testimony and his/her relationship to the
respondent, the relief you plan to request in the petition, and other case characteristics to determine what information should be
provided.
These instructions should be provided to the petitioner as part of the form.
THIS FORM CONTAINS SENSITIVE INFORMATION – 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.
Italicized text that appears within a “box” refers to policy or provides additional information.
NOTE: All section headings contain a checkbox to be used when additional comments/remarks are appropriate. These
comments/remarks should be placed in section IX (Other Pertinent Information).

HEADING/CAPTION:
• 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 and/or respondent is/are affiliated.

• Identify if the petitioner is the obligee or the obligor. This will clarify who is submitting the petition.
• Identify if the respondent is the obligee or the obligor.
• 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.
TANF means the obligee’s family is currently receiving IV-A cash payments. A Medicaid only case is a case in
which the obligee’s 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.

• In the appropriate spaces, if applicable and known, enter the responding jurisdiction’s IV-D case identifier and tribunal number.
The responding jurisdiction is the jurisdiction that is working the case at the request of the initiating jurisdiction.
Under “IV-D case identifier,” 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 “tribunal number”, 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.
• In the appropriate spaces, enter the initiating jurisdiction’s 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
“IV-D case identifier,” 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 “tribunal number”, you may enter the docket number, cause number, or any
other appropriate reference number which the initiating tribunal has assigned to the case.
In the “NOTE” section, check any of the following that apply:
• Nondisclosure Finding/Affidavit attached - If there is a finding prohibiting disclosure of a party’s or child(ren)’s
address/identifying information or an affidavit alleging that disclosure of such information would result in risk of harm,
check the box for “Nondisclosure Finding/Affidavit attached” and attach a copy of the finding/affidavit in accordance with
section 312 of UIFSA. If there is a finding/affidavit prohibiting disclosure, you may provide the address of the IV-D agency
as a substitute address for the protected party.
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General Testimony Instructions
OMB 0970 – 0085
Expiration Date: XX/XX/XXXX
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UIFSA requires that the petition or accompanying documents include certain identifying information regarding the
parties and child(ren) (e.g., residential address, Social Security Number) unless a party alleges in an affidavit or a
pleading under oath that the health, safety, or liberty of a party or child would be jeopardized by disclosure of such
information. In that event, the information must be sealed.
If a jurisdiction has reason to believe that information should not be released because of safety concerns, it should
ensure that there is a nondisclosure finding or an allegation in an affidavit or pleading that disclosure of identifying
information would result in a risk of harm, as provided under section 312 of UIFSA. In addition to identifying
information included on this form, it may be appropriate to submit certain financial information under seal.

• This form sent through EDE - Check if this form was sent through the Electronic Document Exchange (EDE).
The following options are available for making IV-D requests and sending information on IV-D cases:
1. CSENet transactions are the recommended method for making requests or sending information to another
state. If CSENet is not listed as an option on the form, then it cannot be used to convey any of the requests
for information or IV-D requests provided on the form. Supporting documentation should be sent through
EDE, whenever possible. If certified copies are needed, hard copies should also be sent by mail. Mail or fax
may also be used for all documents when EDE is not available.
2. If CSENet transactions are not available in your state, EDE is the next preferred method for transmitting your
request or information. Both your state and the receiving state must be using the EDE application to use this
communication method.
3. If the EDE application is not available in your state or the responding state, then mail or fax must be used to
communicate your request.
• Identify who is providing the testimony. Fill in the full legal name (first, middle, last, suffix) of the individual providing the
testimony and signing the form under penalty of perjury.
Note that testimony is given under penalty of perjury.

Section I. Personal Information About Obligee:
This section asks for information about the obligee. An obligee caretaker only needs to complete section I.E.
The obligee may be the obligee parent (the individual who is owed or is alleged to be owed support), or the
child(ren)’s caretaker (the individual who is responsible for the child(ren), but who is not the parent of the child(ren)).
Part A – Obligee Parent Information:
Item 1: Enter the obligee parent’s full legal name (first, middle, last, suffix).
Item 2: Enter the obligee parent’s gender. Gender is defined as “male”, “female”, or “other”. Select “other” if the person does
not identify as “male” or “female”.

Item 3(a): Enter the obligee parent’s occupation, trade, or profession.

Item 3(b): Enter the obligee parent’s highest attained level of education. The educational level may be used by the

responding tribunal to impute income to an unemployed or underemployed petitioner.
Item 4: Check the appropriate box to indicate the obligee parent’s current tax filing status: single, head of household, married
filing jointly, married filing separately, qualifying widow/widower with dependent children, or unknown if the filing status is not
known. This information may be used by the responding tribunal to determine the obligee’s income when calculating a child
support obligation.
Part B - Physical Description of the Obligee Parent (Attach a recent photo if available.)
Item 1: Provide the obligee parent’s race. When listing the obligee parent’s race, select from the following: 1) White, 2)
Black – African American, 3) American Indian- Alaskan Native, 4) Asian, 5) Native Hawaiian or Other Pacific Islander, 6)

Hispanic/Latino, or 7) Other. You may select more than one race.

Item 2: Provide the obligee parent’s height.

Item 3: Provide the obligee parent’s weight.

Item 4: Provide the obligee parent’s hair color.

Item 5: Provide the obligee parent’s eye color.

Provide any additional physical descriptive information in section IX (Other Pertinent Information).

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Part C - Is the obligee parent financially responsible for dependent children other than those of this action (listed in section
IV)?

Check the appropriate box to indicate whether the obligee parent is responsible for dependents other than the child(ren) in this

action (listed in section IV). If that information is not known, check “unknown.”

If the answer is yes, provide the requested information about each dependent. If there are more than three dependents, provide

information about the other dependents in section IX (Other Pertinent Information).

Item a: Enter the full legal name of the dependent (first, middle, last, suffix).
Item b: Enter the dependent’s year of birth.
Item c: Enter the dependent’s relationship to the petitioner.
Item d: Indicate with whom the dependent is living.
Part D - Does the obligee parent have an order to pay support for any child listed in C above?
Check the appropriate box to indicate whether the obligee parent has been ordered to pay support for any of the dependents
listed in C above. If that information is not known, check “unknown.” If the answer is yes, provide the requested information
about each order, including proof of payment.
If the order requires the obligee parent to pay support to the state disbursement unit (SDU) or another government agency,
provide a copy of all agency payment records.
If payments are paid directly by the obligee parent, provide an affidavit showing dates and amounts of payments made by the
obligee parent under this order. If there are more than three orders, provide information about the additional orders in section
IX (Other Pertinent Information).
Item a: Enter the name(s) of child(ren) covered by the order.
Item b: Enter the amount of the support order.
Item c: Enter the frequency of the amount due, for example, monthly, weekly, bi-weekly.
Item d: Enter the state and the county/tribe/country of the issuing tribunal.
Item e: Enter the order number provided by the issuing tribunal.
Part E – Obligee Caretaker Information: If the obligee is not a parent of the child(ren):
Item 1: Enter the full legal name of the caretaker (first, middle, last, suffix).
Item 2: Indicate the caretaker’s relationship to the child(ren). If the caretaker is a relative, indicate whether he/she is a
maternal (mother’s side of the family) or paternal (father’s side of the family) relative. Examples include: “maternal
grandmother” or “paternal cousin”. Check the box if the caretaker has legal custody/guardianship of the child(ren).
Item 3: Enter the date the child(ren) began residing with the caretaker (month/day/year).
The caretaker should also provide any relevant non-party parent information in section IX (Other Pertinent Information). Such
information includes financial information about the non-party parent, which may be needed for the support guideline calculation.

Section II. Personal Information About Obligor:
This section asks for information about the obligor.
The obligor may be an individual who owes or is alleged to owe the child(ren) a duty of support, or a person who is
alleged but has not been adjudicated to be a parent of the child(ren).
Part A - Obligor Information:
Item 1: Enter the obligor’s full legal name (first, middle, last, suffix)
Item 2: Enter the obligor’s gender. Gender is defined as “male”, “female”, or “other”. Select “other” if the person does not
identify with “male” or “female”.
Item 3(a): Enter the obligor’s occupation, trade, or profession.
Item 3(b): Enter the obligor’s highest attained level of education. The educational level may be used by the responding
tribunal to impute income to an unemployed or underemployed respondent.
Item 4: Check the appropriate box to indicate the obligor’s current tax filing status: single, head of household, married filing
jointly, married filing separately, qualifying widow/widower with dependent children, or unknown if the filing status is not known.
This information may be used by the responding tribunal to determine the obligor’s income when calculating a child support
obligation.

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Part B - Physical Description of the Obligor: (Attach a recent photo if available.)
Item 1: Provide the obligor’s race. When listing the obligor’s race, select from the following: 1) White, 2) Black – African
American, 3) American Indian- Alaskan Native, 4) Asian, 5) Native Hawaiian or Other Pacific Islander, 6) Hispanic/Latino,
or 7) Other. You may select more than one race.
Item 2: Provide the obligor’s height.
Item 3: Provide the obligor’s weight.
Item 4: Provide the obligor’s hair color.
Item 5: Provide the obligor’s eye color.
Provide any additional physical descriptive information in section IX (Other Pertinent Information).
Part C - Is the obligor financially responsible for dependent children other than those of this action (listed in section IV)?
Check the appropriate box to indicate whether the obligor is responsible for dependents other than the child(ren) in this action
(listed in section IV). If that information is not known, check “unknown.”
If the answer is yes, provide the requested information about each dependent, if known. If there are more than three
dependents, provide information about the other dependents in section IX (Other Pertinent Information).
Item a: Enter the full legal name of the dependent (first, middle, last, suffix).
Item b: Enter the dependent’s year of birth.
Item c: Enter the dependent’s relationship to the respondent.
Item d: Indicate with whom the dependent is living.
Part D - Does the obligor have an order to pay support for any child listed in C above?
Check the appropriate box to indicate whether the obligor has been ordered to pay support for any of the dependents listed in C
above. If that information is not known, check “unknown.” If the answer is yes, provide the requested information about each
order, if known, and attach a copy of the order, if available.
If the order requires the obligor to pay support to the state disbursement unit (SDU) or another government agency, provide a
copy of all agency payment records.
If payments are paid directly by the obligor, provide an affidavit showing dates and amounts of payments made by the obligor
under this order. If there are more than three orders, provide information about the additional orders in section IX (Other
Pertinent Information).
Item a: Enter the name(s) of child(ren) covered by the order.
Item b: Enter the amount of the support order.
Item c: Enter the frequency of the amount due, for example, monthly, weekly, bi-weekly.
Item d: Enter the state and the county/tribe/country of the issuing tribunal.
Item e: Enter the order number provided by the issuing tribunal.

Section III. Legal Relationship of Parents of Children Listed in Section IV:
Identify the legal relationship between the parents of the child(ren) listed in section IV (Dependent Children in This Action). Check
all appropriate boxes and enter the pertinent corresponding information.
Item A: Check this box if the parents were never married to each other.
Item B: Check this box if the parents were married to each other. Indicate the date (month, day, year) and state and
county/tribe/country of the marriage.
Item C: Check this box if the parents were married by common law. Indicate the time period (dates) and state and
county/tribe/country of the common law marriage.
Item D: Check this box if the parents are legally separated. Indicate the date (month, day, year) and state and
county/tribe/country of the legal separation.
Item E: Check this box if divorce proceedings are pending. Indicate the state and county/tribe/country of the proceedings.
Item F: Check this box if the parents are divorced. Indicate the date (month, day, year) and state and county/tribe/country
of the finalized divorce.
Item G: Check this box to indicate other relationships not described by the options above. Describe the relationship, such as
domestic partnership or civil union, on the line provided.

Section IV. Dependent Child(ren) in This Action:
List all the children of this action for whom parentage/support is to be established or for whom support is to be modified. These should
be the same children listed in section I of the Uniform Support Petition. List only those children of the particular obligor named in this
action. Provide information about each child under parts A – C below. Check “See section IX” when there are more than three
dependent children in this action. Include all of the information listed below for the additional children listed in section IX (Other
Pertinent Information). Attach additional pages if needed.
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Item 1: Enter the child’s full legal name (first, middle, last, suffix).

Item 2: Check the appropriate box to indicate if the parentage of the child has been legally established. If the answer is no,

attach a separate “Declaration in Support of Establishing Parentage” for each child whose parentage is at issue.

Item 3: Provide the amount of child care paid on a monthly basis for this child, if applicable. Provide any additional information

related to child care in section IX (Other Pertinent Information).

Item 4: Check the appropriate box to indicate whether a child support order has been established for this child.

Item 5: Check the appropriate box to indicate whether the child is living with the petitioner.

Item 6: Check the appropriate box to indicate whether any benefits are received for the child, for example: Supplemental

Security Income (SSI), Social Security Disability Income (SSDI); Social Security Retirement Income (SSRI); Veteran’s Disability

Income; Railroad Retirement Income (RRB Retirement); Railroad Retirement Disability (RRB Disability). If the answer is yes,

provide the benefit type and the amount received on a monthly basis on behalf of the child. Identify the claimant and the

claimant’s relationship to the child in the spaces provided. If the child receives SSI based on the child’s disability, enter the

child’s name in the line, “Based on claim of ____” and enter “Self” in the line, “Relationship to child____”.

Item 7: Check the appropriate box to indicate whether there is a tribal affiliation. Enter the basis of tribal affiliation, i.e., adoption,

descendency.

SECTION V. HEALTH CARE COVERAGE:
This information is used to determine if health care coverage is currently being provided for the dependents. The information also
provides a basis for adding health care coverage to new or existing orders.
Health care coverage may include, but is not limited to, Medicaid, TRICARE, Indian Health Service, employer coverage,
individual policy, state or federal health insurance exchange/marketplace policy, and cash medical.
Part A – Health Care Coverage for Child(ren):

NOTE: Provide health care information for each child listed in section IV (Dependent Children in This Action).

If there are more than three children, provide the requested information for the other children in section IX (Other Pertinent

Information).

Item 1 - Child 1
Item a: Enter the name of the child and check the appropriate box to indicate whether the child currently has health care
coverage. If yes, complete items b through f. If no or unknown, skip to item e.
Item b: Check all of the health care coverage boxes that apply to indicate the source of the child’s health care coverage. If
coverage is provided only through Medicaid, CHIP, TRICARE, or Indian Health Service, indicate which one and skip to item
e. If coverage is provided through multiple sources or a different listed source, select the appropriate box(es) and then
continue to item c. An individual policy includes policies obtained through the federal or state exchange/marketplace.
Check “Other Person” if someone other than the petitioner or respondent is providing health care coverage for the child.
Enter that person’s name and relationship to the child, for example, maternal stepfather or paternal grandmother.
Item c: In the appropriate spaces, enter the name, address, policy ID number, and group number of the health care

provider through which the child is covered. If more than one health care coverage provider is selected in item b, provide

the additional information in section IX (Other Pertinent Information).

Item d: Check whether the child is covered through a “child only” policy. If yes, enter the monthly premium for this child

only.

Item e: Check the appropriate box to indicate who claims the child as a dependent for federal tax purposes. If a person

other than one of the parents claims the dependency exemption for the child, provide the person’s name and relationship to

the child. Attach a copy of any order that identifies who can claim the dependency exemption.

Item f: Check the appropriate box to indicate if the dependency exemption changes from year to year. If yes, provide
details in section IX (Other Pertinent Information), for example, obligee claims child in odd-numbered years and obligor in
even-numbered years.
Item 2 - Child 2
Item a: Enter the name of the child and check the appropriate box to indicate whether the child currently has health care
coverage. If no or unknown, skip to item 2e. If yes, indicate whether the health care coverage is the same as that for Child
1. If it is, skip to item 2e. If it is not, continue to item 2b.

Items b - f: Follow the instructions provided above.

Item 3 - Child 3
Item a: Enter the name of the child and check the appropriate box to indicate whether the child currently has health care
coverage. If no or unknown, skip to item 3e. If yes, indicate whether the health care coverage is the same as that for Child
1. If it is, skip to item 3e. If it is not, continue to item 3b.

Items b - f: Follow the instructions provided above.

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Part B – Health Care Coverage for Petitioner:
Check the appropriate box to indicate if the petitioner has health care coverage. If yes, complete items 1 through 6. If the petitioner
currently does not have health care coverage, skip to item 4.
Item 1: Check the appropriate box to indicate the source of the petitioner’s health care coverage. If health care coverage is
provided through Medicaid, skip to item 4. If health care coverage is provided through TRICARE or Indian Health Service,
indicate which one and skip to part C. Otherwise, select whether the health care coverage is provided through an employer or
an individual/private policy, which includes policies obtained through the federal or a state exchange/marketplace. Check
“Other person” if someone other than the petitioner is providing the health care coverage and enter that person’s name and
relationship to the petitioner, for example, petitioner’s current spouse.
Item 2: In the appropriate spaces, enter the name and address of the health care provider through which the petitioner is
covered. Enter the policy ID number, group number, monthly premium, and the portion of the monthly premium for the child(ren)
listed in section IV (Dependent Children in This Action).
If the premium is paid weekly, the monthly cost is calculated by multiplying the weekly cost by 52 and dividing by 12. If the premium
is paid bi-weekly, the monthly cost is calculated by multiplying the bi-weekly cost by 26 and dividing by 12. If the premium is paid
semi-monthly, the monthly cost is calculated by multiplying the semi-monthly cost by 2. If the premium is paid quarterly, the
monthly cost is calculated by dividing the quarterly cost by 3. If the premium is paid annually, the monthly cost is calculated by
dividing the annual cost by 12.
Item 3: Check the appropriate box to indicate if any other adults and/or child(ren) not listed in section IV are covered by the
petitioner’s policy and, if yes, enter the total number of adults and/or the total number of child(ren) in the appropriate space.
Item 4: If the petitioner does not have health care coverage or coverage is through Medicaid, check the appropriate box to
indicate if the petitioner has employer-sponsored coverage available to self (item 4.a) and/or child(ren) listed in section IV (item
4.b). If coverage is not available for the child(ren) listed in section IV, skip to part C.
Item 5: Check the appropriate box to indicate if the petitioner’s employer-sponsored insurance is accessible to the child(ren)
listed in section IV. If no, skip to part C.
Item 6: Enter the cost of premiums for health care coverage not currently in effect but available through the petitioner’s
employer. In item 6.a, include the cost for coverage for the petitioner. In item 6.b., include only the cost of premiums for the
child(ren) listed in section IV. Indicate for both the petitioner and the child(ren) the frequency of premium payments, for
example, weekly, bi-weekly, semi-monthly, monthly, quarterly, yearly.
Part C – Health Care Coverage for Respondent:
Check the appropriate box to indicate if the respondent has health care coverage. If yes, complete items 1 through 6. If the
respondent currently does not have health care coverage, skip to item 4. If unknown, skip to part D.
Item 1: Check the appropriate box to indicate the source of the respondent’s health care coverage. If health care coverage is
provided through Medicaid skip to item 4. If health care coverage is provided through TRICARE or Indian Health Service,
indicate which one and skip to part D. Otherwise, select whether the coverage is provided through an employer or an individual
policy, which includes policies obtained through the federal or a state exchange/marketplace. Check “Other person” if someone
other than the respondent is providing the health care coverage and enter that person’s name and relationship to the
respondent, for example, spouse or parent.
Item 2: In the appropriate spaces, enter the name and address of the health care provider through which the respondent is
covered. Enter the policy ID number, group number, monthly premium, and the portion of the monthly premium for the
child(ren) listed in section IV (Dependent Children in This Action).
Item 3: Check the appropriate box to indicate if any other adults and/or child(ren) not listed in section IV are covered by the
respondent’s policy and, if yes, enter the total number of adults and/or the total number of children in the appropriate space.
Item 4: If the respondent does not have health care coverage or coverage is through Medicaid, check the appropriate box to
indicate if the respondent has employer-sponsored coverage available to self (item 4.a) and/or child(ren) listed in section IV
(item 4.b). If coverage is not available for the child(ren) listed in section IV, skip to part D..
Item 5: Check the appropriate box to indicate if the respondent’s employer-sponsored insurance is accessible to the child(ren)
listed in section IV. If no, skip to part D.
Item 6: Enter the cost of premiums for health care coverage not currently in effect but available through the respondent’s
employer. In item 6.a, include only the cost for coverage for the respondent. In item 6.b., include only the cost of premiums for
the child(ren) listed in section IV. Indicate for both the respondent and the child(ren) the frequency of premium payments, for
example, weekly, bi-weekly, semi-monthly, monthly, quarterly, yearly.
When establishing a support order, the law of the responding jurisdiction determines whether and how past and
ongoing medical expenses are included in the support order. For example, some states consider only expenses
above a threshold amount or those costs that are for specific ongoing costs. The expenses in parts D through F
may not be reimbursable or allowed in all jurisdictions.

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Part D - Check the appropriate box to indicate whether any of the child(ren) listed in section IV (Dependent Children in This Action)
have special needs or extraordinary medical expenses not covered by insurance. This includes special medical needs, medical
equipment, counseling, special schooling, etc. If yes, provide information in section IX (Other Pertinent Information) about the
child(ren) involved, the type(s) of need/expense, and the related costs. Attach documentation of the special medical need, such as a
doctor’s statement. If special needs are indicated, explain in detail any agreement between the petitioner and respondent to cover
these costs, including agreements that are verbal, written, or part of any court or administrative order. If you do not know, check
“Unknown.”
Part E - Check the appropriate box to indicate whether the petitioner is requesting reimbursement from the respondent for any
medical expenses paid. If yes, enter the balance and the date accrued. Provide the date, type of expense (such as doctor visit,
prescriptions), and cost in section IX (Other Pertinent Information).
Part F - Check the appropriate box to indicate whether the petitioner is asking the tribunal to order the respondent to share the cost of
an ongoing medical expense being paid by the petitioner and not covered by insurance, such as dental services co-payments and
allergy shots. If yes, enter the type of medical expense and the amount and frequency of the cost. Provide additional information in
section IX (Other Pertinent Information) about the child(ren) involved and attach supporting documentation of the need and expense.

Section VI. Additional Information for Child Support Calculation:
This information may be used by the responding tribunal to establish a support order or modify an existing one. State child support
guidelines vary in whether the information is relevant to the calculation. Complete the appropriate section depending on the action
sought.
Part A - Establishment:
Complete this section if the petitioner is requesting the responding tribunal to set a current support obligation for the child(ren) listed in
section IV and no support order exists.
Some state child support guidelines consider the amount of time the child(ren) spend with the obligor. Generally,
states use the number of overnights the child(ren) spends with the obligated parent to calculate any applicable
adjustment/deviation. States may require a court order or binding separation agreement indicating
custody/parenting time terms. Items 1-3 request information that may be relevant to the responding tribunal.
Item 1: Check the appropriate box to indicate whether a custody/parenting time order exists. If yes, provide the issuing tribunal
number and the date the order was issued. A copy of the custody/parenting time order must be attached to the General
Testimony.
Item 2: If a custody/parenting time order does not exist, check the appropriate box to indicate whether there is a written
agreement between the parties on custody/parenting time. If yes, a copy of the agreement must be attached to the General
Testimony.
Item 3: Indicate how many overnights the child(ren) have spent with the obligee and with the obligor in the 12 months prior to
filing this action or since separation, whichever is the shorter period.
The award of support for a period of time prior to the date of filing the support petition is not required under federal
law but may be appropriate in accordance with state law. Not all states have authority to establish support orders
for prior periods. However, the period of time the family received TANF benefits may be a relevant factor in setting
an award for a prior period; this section provides space for this information.

When establishing an order, a state must use its child support guidelines as a rebuttable presumption. States may
establish child support awards covering a prior period, but such awards must be based on guidelines and take into
consideration the obligor’s earnings and income during the prior period.
Item 4: Check the appropriate box to indicate whether child support is sought for a period prior to the date the Uniform Support
Petition was signed. If yes, complete the following questions and section VIII (Financial Information):
Item a: Provide the date from which the obligee seeks retroactive support, for example, the date of birth of the child, or the
date the parties separated.
Item b: Check the appropriate box to indicate whether the child(ren) resided with the obligor during any period for which

retroactive support is sought beyond the time specified in a custody/parenting time order or agreement. If yes, detail the

additional time. For example, if there is no order or agreement and the child spent 6 months of the past year residing with the

obligor, report that information here and in section IX (Other Pertinent Information) if additional space is needed.

Item c: Check the appropriate box to indicate whether the obligor provided payments directly to the obligee for the

child(ren)’s support. If yes, provide an affidavit of payments showing those direct support payments.

Item d: Check the appropriate box to indicate whether public assistance was paid for the child(ren) during the period

retroactive support is sought. If yes, check the appropriate box(es) and provide the period of the public assistance benefit

and the state. If there are multiple dates, explain and include documentation in section IX (Other Pertinent Information).

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Part B - Modification:
Complete this section if the petitioner is requesting the responding tribunal to modify an existing support order for the child(ren) listed in
section IV (Dependent Children in This Action).
Item 1: In this section indicate the basis for the modification petition. Check all that apply, based on changes since entry of the
most recent order.
Item a: The earnings of the obligor have either substantially increased or substantially decreased.

Item b: The earnings of the obligee have either substantially increased or substantially decreased.

Item c: The needs of the child(ren) have either substantially increased or substantially decreased.

Item d: The current support order was most recently established or modified at least 3 years ago or such lesser time as

permitted by the laws of the responding jurisdiction.

Item e: Other (For example, the health care coverage or needs have changed); explain.

Item 2: In this section indicate if a custody/parenting time order exists. If yes, attach a copy of the order and fill in the issuing

tribunal number and the date of the order.

Item 3: In this section, if a custody/parenting time order does not exist, indicate if there is a written custody/parenting time

agreement. If yes, attach a copy of the agreement.

Item 4: In this section indicate the number of overnights, in the past 12 months or since separation (whichever is shorter), the

child(ren) have had with either the obligee or obligor.

Section VII. Support Order and Payment:
This information is used to justify the support arrears (past-due support), if any, claimed in the petition.

Part A - Check the appropriate box to indicate whether there is an order for divorce or legal separation involving the children

in this action. If the answer is yes, provide a copy of the order.

Part B - Check the appropriate box to indicate whether a current support order exists. If a support order exists, attach a certified
copy of the obligor’s payment record for payments ordered through the state disbursement unit (SDU) or other government
agency or an affidavit of payments made directly to the obligee. Such direct payments to the obligee may include payments
made by military allotment that did not go through the SDU.
Part C - Check the appropriate box to indicate whether the support order requires the obligor to make additional payments directly to
the obligee, child care provider or health care provider; a private school for tuition, books or fees; or the obligee for a share of the
health insurance premium or medical expense. If the answer is yes, complete part D below.
Part D - Check the appropriate box to indicate whether the obligor has made any direct payments pursuant to the order noted in part
C. If payments have been made, attach an affidavit of payments that lists the dates, amounts, and purpose of such payments, as well
as the individual or entity to whom the payments were made.
Part E - Check the appropriate box to indicate whether the obligor has made any voluntary support payments in the absence of a
support order. If payments have been made, attach an affidavit of payments that lists the dates, amounts, and purpose of such
payments, as well as the individual or entity to whom the payments were made.

Section VIII. Financial Information:
This section is used to obtain the petitioner’s financial information needed to apply the responding jurisdiction’s child support guidelines
to determine the appropriate amount of support. If the petitioner is a caretaker without legal custody of the child(ren), this section does
not need to be filled out.
It is important to disclose all the information. Failure to disclose information may seriously affect the legal proceedings
in the responding jurisdiction and may unnecessarily delay the resolution of the support issue.
Part A - Monthly Income From All Sources:
Item 1: Check the appropriate box to indicate whether the individual petitioner is employed. If yes, list the occupation. If no,

list the income source.

Item 2: List the gross monthly income of the individual petitioner. List the income source separately under the categories

provided in item 2. Be sure to provide information regarding all earnings and income sources, including salaries, wages,

commissions, fees, bonuses, tips, and public assistance. You should consider seasonal or intermittent income on an annual

basis (total for the year divided by 12).

Item a: Enter the gross monthly amount of any public assistance received, including Supplemental Security Income (SSI)

and Temporary Assistance for Needy Families (TANF). “Other” includes other types of cash public assistance.

Item b: Enter the gross monthly amount of base pay salary or wages.

Item c: Enter the gross monthly amount of overtime, commissions, tips, bonuses, and additional part time pay.

Item d: Enter the gross monthly amount of unemployment compensation received.

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Item e: Enter the gross monthly amount of worker’s compensation received.
Item f: Enter the gross monthly amount of Social Security Disability income (SSDI) received by
and for the petitioner.
Item g: Enter the gross monthly amount of Social Security Retirement income (SSRI) received by
and for the petitioner.
Item h: Enter the gross monthly amount of dividends and interest received.
Item i: Enter the gross monthly amount of trust/annuity income received.
Item j: Enter the gross monthly amount of pension or retirement income received, except SSRI, which is entered in item g.
Item k: Enter the gross monthly amount of any child support payments received.
Item l: Enter the gross monthly amount of any spousal support/alimony received.
Item m: Enter the gross monthly amount received from income-producing assets, such as rental property.
Item n: Under “All other sources”, include and describe monthly amounts for other income regularly received, such as
self-employment income, or regular in-kind income. If income is received on other than a monthly basis, annualize and
divide by 12.
Item 3: On the appropriate lines, enter the deductions from gross pay.
Item a: Enter the gross monthly amount deducted for federal income tax.
Item b: Enter the gross monthly amount deducted for state income tax.
Item c: Enter the gross monthly amount deducted for local tax.
Item d: Enter the gross monthly amount deducted for FICA.
Item 4: On the appropriate lines, enter other deductions for the individual petitioner. Note that under some state
support guidelines, these items are considered deductions while under other state support guidelines they are
considered expenses.
Item a: “Mandatory retirement” means amounts that are required by law to be withheld or paid directly from a party’s income
and deposited in a retirement account or fund.
Item b: “Nonmandatory retirement” means amounts that are voluntarily withheld or paid directly from a party’s income and
deposited in a retirement account or fund.
Item c: “Medical insurance” means medical insurance premiums withheld or paid from a party’s income.
Item d: “Union dues” means mandatory union dues that are withheld or paid directly from a party’s income.
Item e: “Other (specify)” includes all other deductions, such as support obligations listed in section I.D or II.D; state
unemployment insurance tax and disability insurance premiums, where applicable; and certain employment-related
expenses that are deducted directly from income. Include an explanation in the space provided.
Item 5: Enter the individual petitioner’s gross income for the prior year.

Section IX. Other Pertinent Information:
In this section, provide additional information that may be useful to the responding jurisdiction. For example, if there are multiple
periods of public assistance, you may use this section to provide that information. If the petitioner is an obligee caretaker, you may use
this section to provide financial information about the non-party parent. Additional information may also include information about a
party’s real estate, bank accounts, IRA accounts, or money market accounts. If the additional information is related to a previous
section, identify the section, part, and item number as appropriate. Check “Continued on attached sheet(s), incorporated by
reference.” if you have more information than will fit into the space provided.

Section X. Attached and Incorporated by Reference:
Check the appropriate box(es) to indicate all documents attached. If a support order was not issued by the responding jurisdiction,
you will generally need to attach one certified copy and one copy. If the order was issued by the responding jurisdiction, you may
not need to include a copy of the order, but it can be helpful to the responding jurisdiction.
Check “Additional attached document(s), incorporated by reference.” for documents other than those listed.

Section XI. Declaration:
The person providing the testimony – the individual petitioner and/or agency representative – must sign under penalty of perjury and
date the General Testimony at the bottom of the page. By this signature, the individual and/or agency representative is confirming that
the information and facts provided in the testimony and all attached documents are true to the best of his/her knowledge and belief.

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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 emails may be used if the encryption method is compliant with Federal
Information Processing Standard (FIPS) Publication 140-2 (FIPS PUB 140-2).

The Paperwork Reduction Act of 1995
Public reporting burden for this collection of information is estimated to average 0.33 hours per response, including the time for

reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information.

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a

currently valid OMB control number.

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