General Testimony Page 8
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30GENERAL TESTIMONY, PAGE 7
Initiating IV-D Case No.
VIII. Obligee's Public Assistance Status
[ ]
See Section X
[If no public assistance was paid, skip to Section IX.]
1. Period during which public assistance was paid:
From:_______________/__________ To:_______________/__________by:____________________________
First month
year
Last month
year
State
2. Total amount of public assistance paid: $______________________ as of ___________________________
Date
3. Medical assistance related to prenatal, postnatal, or general expenses was paid in the amount of $_____________
by: _______________________________________________________________________________.
Agency or Person
IX. Financial Information
[ ]
See Section X
Information required varies based on responding State's guidelines. Updates may be required.
A. Monthly Income from All Sources:
[ ]
[ ]
1. Is the petitioner employed?
Yes; occupation:___________________
No; income source:_________________
2. Gross Monthly Income Amounts:
Petitioner
Current Spouse/Partner
Obligor's Dependent(s)
a) Public Assistance
i) SSI
$_______________
$________________
$________________
ii) Family Assistance
$_______________
$________________
$________________
iii) Other
$_______________
$________________
$________________
b) Base pay salary, wages
$_______________
$________________
$________________
c) Overtime, commissions,
tips, bonuses, parttime
$_______________
$________________
$________________
d) Unemployment compensation
$_______________
$________________
$________________
e) Worker's compensation
$_______________
$________________
$________________
f) Social Security Disability
$_______________
$________________
$________________
g) Social Security Retirement
$_______________
$________________
$________________
h) Dividends and interest
$_______________
$________________
$________________
i) Trust/Annuity Income
$_______________
$________________
$________________
j) Pensions,retirement
$_______________
$________________
$________________
k) Child support
$_______________
$________________
$________________
l) Spousal support/alimony
$_______________
$________________
$________________
m) All other sources
$_______________
$________________
$________________
Explain "other sources":______________________________________________________
3. Total Gross Monthly
$_______________
$________________
$________________
(lines "2a" through "2m")
4. Deductions From Gross
a) Federal Income Tax
$_______________
$________________
$________________
General Testimony
Page 7 of 10
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