General Testimony Page 2
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30GENERAL TESTIMONY, PAGE 2
Initiating IV-D Case No.
D. Information about Current Spouse or Partner of Child(ren)'s Mother
1. Name of New Spouse or Non-Marital Partner
2. Is Current Spouse/Partner Employed?
(First, Mid, Last)
[ ]
[ ]
[ ]
Yes
No
Unknown
3. Name and Address of Spouse's/Partner's Employer
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
No
Unknown (If yes, provide information below.)
1.
a. Full Name
b. Date of Birth
(First, Mid, Last)
c. Relationship
d. Living With:
e. Source of Support/Income
f. Monthly Amount; Gross:
Net:
2.
a. Full Name
b. Date of Birth
(First, Mid, Last)
c. Relationship
d. Living With:
e. Source of Support/Income
f. Monthly Amount; Gross:
Net:
3.
a. Full Name
b. Date of Birth
(First, Mid, Last)
c. Relationship
d. Living With:
e. Source of Support/Income
f. Monthly Amount; Gross:
Net:
II. Personal Information About Child(ren)'s Father
[ ]
See Section X
[ ]
[ ]
[ ]
A.1. Father 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 Father (Optional: Attach photo if available.)
1. Race
2. Height
3. Weight
4. Hair Color
5. Eye Color
General Testimony
Page 2 of 10
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