General Testimony Page 4
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30GENERAL TESTIMONY, PAGE 4
Initiating IV-D Case No.
IV. Legal Relationship of Parents
[ ]
See Section X
[ ]
[ ]
1.
Never married to each other
2.
Married on _______________________in ______________________________
Date
County/State
[ ]
3.
Married by common law for the period __________________________in_____________________________________
Dates
County/State
[ ]
[ ]
4.
Separated on _______________
5.
Divorced on ________________in_____________________________
Date
Date
County/State
[ ]
6.
Legally separated on___________________in________________________________
Date
County/State
[ ]
[ ]
7.
Divorce pending in________________________________
8.
Support Order Entered on ____________________
County/State
Date
[ ]
[ ]
9.
No support order
10.
Other______________________________________________________________
11. Tribunal & Location (Divorce, Legal Separation, Support Order):
V. Dependent Child(ren) in this Action
[ ]
See Section X
[ ]
A. List obligor's (named on page 1 of this form) child(ren) only.
Nondisclosure Finding Attached
1.
a. Full Name
f. Paternity Established?
(First, Mid, Last)
[ ]
[ ]
Yes
No
b. Address
g. Support Order Established?
[ ]
[ ]
Yes
No
c. Social Security Number
h. Living with Petitioner?
[ ]
[ ]
Yes
No
d. Sex
e. Date of Birth
2.
a. Full Name
f. Paternity Established?
(First, Mid, Last)
[ ]
[ ]
Yes
No
b. Address
g. Support Order Established?
[ ]
[ ]
Yes
No
c. Social Security Number
h. Living with Petitioner?
[ ]
[ ]
Yes
No
d. Sex
e. Date of Birth
3.
a. Full Name
f. Paternity Established?
(First, Mid, Last)
[ ]
[ ]
Yes
No
b. Address
g. Support Order Established?
[ ]
[ ]
Yes
No
c. Social Security Number
h. Living with Petitioner?
[ ]
[ ]
Yes
No
d. Sex
e. Date of Birth
General Testimony
Page 4 of 10
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