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7County/State/Court
Type of custody action
Date Filed
Status
9. Other Persons with Claims to Children: (If there are minor children, check (a) or (b):)
a) I know of no other person, not a party to this proceeding, who has physical custody of the
children or claims to have custody or visitation rights with respect to the minor children.
b) The following persons who are not a party to this proceeding have custody or visitation
rights with the minor children:
Name
Claim
10. Child Support: (Complete if there are minor children. Check (a) or (b).)
a) I am employed by
earning
per
month. The Respondent is an able bodied person capable of earning sufficient money to
support the minor children. Respondent is employed by
earning
per month and I am in need
of financial assistance from the Respondent for the support of the minor children.
I □ have □ have not completed the Child Support Worksheet and Schedules pursuant to the Georgia
Child Support Guidelines which became effective January 1, 2007.
b) The issues of child support cannot be decided in this action because Georgia does not
have personal jurisdiction over my spouse.
11. Health Insurance for Minor Children: (Complete if there are minor children. (Check (a), (b) or
(c):)
a) Respondent should be ordered to maintain a policy for dental, medical, and
hospitalization insurance for the minor children. (Check (1), (2) or (3))
(1)
Respondent should be responsible for uncovered costs.
(2)
The parties should share the uncovered costs.
(3)
Petitioner should be responsible for uncovered costs.
b) Respondent and I should share the costs of dental, medical, and hospitalization
insurance for the minor children. (Check (1), (2) or (3))
(1)
Respondent should be responsible for uncovered costs.
(2)
The parties should share the uncovered costs.
(3)
Petitioner should be responsible for uncovered costs.
c) The issue of health insurance for the children cannot be decided in this action because
Georgia does not have jurisdiction over my spouse.
12. Life Insurance for the Minor Children: (Check if there are minor children, and you want your
spouse to have life insurance for the minor children. Check (a) or (b):)
a) Respondent should be ordered to maintain life insurance for the benefit of the minor
children.
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