General Testimony Page 12
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30GENERAL TESTIMONY, PAGE 10
Initiating IV-D Case No.
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 paystubs 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.
[ ]
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
Notary Public, Tribunal/Agency
Commission Expires
General Testimony
Page 10 of 10
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