General Testimony

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GENERAL TESTIMONY
[ ]
Petitioner
IV-D Non Public Assistance
[ ]
IV-D Non PA Medicaid
[ ]
Full Services
[ ]
Medical Services Only
[ ]
Respondent
IV-D Public Assistance
[ ]
IV-E Foster Care (IV-D Case)
File Stamp
[ ]
Non IV-D
Responding IV-D Case No. __________________________________
Initiating IV-D Case No. __________________________________
Responding Docket No. _____________________________________
Initiating Docket No. _____________________________________
[ ]
[ ]
Petitioner is:
Obligee
Caretaker Other than Parent
[ ]
[ ]
Obligor
Foster Care
[ ]
[ ]
Respondent is:
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 [ ]
See Section X
[ ]
[ ]
[ ]
A.1. Mother is:
Obligee
Obligor
2.
Nondisclosure Finding Attached
3. Full Name
(First, Mid, Last; include nickname, alias)
[ ]
5. Social Security Number
6. Date of Birth
4. Home Address
Confirmed______________(date)
7. Home Phone
8. Work Phone
(
)
(
)
[ ]
10(a). Occupation, Trade or Profession
9. Employer
Name & Address
Confirmed_________(date)
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 (Optional: 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
7.
Unknown
General Testimony
OMB No. 0970 - 0085
Page 1 of 10

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