General Testimony Page 3
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30GENERAL TESTIMONY, PAGE 3
Initiating IV-D Case No.
C. Present Marital 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 or Partner of Child(ren)'s Father
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 father 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:
III. Personal Information About Caretaker Other than Parent
[ ]
See Section X
1. Caretaker's Relation to Child is:
[ ]
2.
Nondisclosure Finding Attached
3. Full Name
(First, Mid, Last; include nickname, alias)
[ ]
5. Social Security Number
6. Date of Birth
7. Sex
4. Home Address
Confirmed____________(date)
8. Home Phone
9. Work Phone
(
)
(
)
[ ]
11(a). Occupation, Trade or Profession
10. Employer
Name & Address
Confirmed_______(date)
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
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