Use this template/form to file for child custody in the state of New Jersey
Text version of this Form
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GENERAL TESTIMONY
Petitioner: Name (first, middle, last) IV-D Case: [ ] TANF
Social Security Number [ ] IV-E Foster Care
[ ] Medicaid Only
[ ] Former Assistance
Respondent: Name (first, middle, last) [ ] Never Assistance File Stamp
Social Security Number Non-IV-D Case: [ ]
Responding IV-D Case Number
Responding Tribunal Number
Initiating IV-D Case Number
Initiating Tribunal Number
Petitioner is: [ ] Obligee [ ] Caretaker Other than Parent
[ ] Obligor [ ] Foster Care
Respondent is: [ ] Obligee [ ] Caretaker Other than Parent
[ ] Obligor [ ] Foster Care
____________________________________________ being duly sworn, under penalties of perjury, testifies as follows:
Name (first, middle, last)
I. Personal Information About Child(ren)’s Mother [ ] See Section X
A.1. Mother is: [ ] Obligee [ ] Obligor 2. [ ] Nondisclosure Finding Attached
3. Full Name (first, middle, last)
Nickname, alias, maiden name, former married name, etc.
4. Home Address [ ] Confirmed______________(date) 5. Social Security Number 6. Date of Birth
7. Home Phone 8. Work Phone
( ) ( )
9. Employer Name & Address [ ]Confirmed____________ (date) 10(a). Occupation, Trade or Profession
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 Mother (Attach photo if available.)
1. Race 2. Height 3. Weight 4. Hair Color 5. Eye Color
C. Present Marital Status of Child(ren)’s Mother
1. [ ] Married 2. [ ] Single 3. [ ] Living with Non-Marital Partner
4. [ ] Divorced 5. [ ] Legally Separated 6. [ ] Separated 7. [ ] Unknown
General Testimony OMB 0970 – 0085 Expiration Date: 01/31/2011 Page 1 of 10
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GENERAL TESTIMONY, PAGE 2 Initiating IV-D Case Number
D. Information about Current Spouse or Partner of Child(ren)’s Mother
1. Name of Current Spouse or Partner (first, middle, last) 2. Is Current Spouse/Partner Employed?
[ ] 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 (first, middle, last) b. Date of Birth
c. Relationship d. Living With:
e. Source of Support/Income f. Monthly Amount; Gross: Net:
2. a. Full Name (first, middle, last) b. Date of Birth
c. Relationship d. Living With:
e. Source of Support/Income f. Monthly Amount; Gross: Net:
3. a. Full Name (first, middle, last) b. Date of Birth
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, middle, last)
Nickname, Alias
4. Home Address [ ] Confirmed______________(date) 5. Social Security Number 6. Date of Birth
7. Home Phone 8. Work Phone
( ) ( )
9. Employer Name & Address [ ] Confirmed____________(date) 10(a). Occupation, Trade or Profession
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 (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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GENERAL TESTIMONY, PAGE 3 Initiating IV-D Case Number
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 Current Spouse or Partner (first, middle, last) 2. Is Current Spouse/Partner Employed?
[ ] 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 (first, middle, last) b. Date of Birth
c. Relationship d. Living With:
e. Source of Support/Income f. Monthly Amount; Gross: Net:
2. a. Full Name (first, middle, last) b. Date of Birth
c. Relationship d. Living With:
e. Source of Support/Income f. Monthly Amount; Gross: Net:
3. a. Full Name (first, middle, last) b. Date of Birth
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:
[ ] Has legal custody/guardianship of child 2. [ ] Nondisclosure Finding Attached
3. Full Name (first, middle, last)
Nickname, alias, maiden name, former married name, etc.
4. Home Address [ ] Confirmed____________(date) 5. Social Security Number 6. Date of Birth 7. Sex
8. Home Phone 9. Work Phone
( ) ( )
10. Employer Name & Address [ ]Confirmed___________(date) 11(a). Occupation, Trade or Profession
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
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GENERAL TESTIMONY, PAGE 4 Initiating IV-D Case Number
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 Legal Name (first, middle, last) f. Paternity Established?
[ ] Yes (check how) [ ] No
[ ] By order
b. Address
[ ] By voluntary acknowledgment
[ ] By adoption
[ ] By conclusive marital presumption
[ ] Other:
c. Social Security Number g. Support Order Established?
[ ] Yes [ ] No
d. Sex e. Date of Birth h. Living with Petitioner?
[ ] Yes [ ] No
2. a. Full Legal Name (first, middle, last) f. Paternity Established?
[ ] Yes (check how) [ ] No
[ ] By order
b. Address
[ ] By voluntary acknowledgment
[ ] By adoption
[ ] By conclusive marital presumption
[ ] Other:
c. Social Security Number g. Support Order Established?
[ ] Yes [ ] No
d. Sex e. Date of Birth h. Living with Petitioner?
[ ] Yes [ ] No
3. a. Full Legal Name (first, middle, last) f. Paternity Established?
[ ] Yes (check how) [ ] No
[ ] By order
b. Address
[ ] By voluntary acknowledgment
[ ] By adoption
[ ] By conclusive marital presumption
[ ] Other:
c. Social Security Number g. Support Order Established?
[ ] Yes [ ] No
d. Sex e. Date of Birth h. Living with Petitioner?
[ ] Yes [ ] No
General Testimony Page 4 of 10
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GENERAL TESTIMONY, PAGE 5 Initiating IV-D Case Number
4. a. Full Legal Name (first, middle, last) f. Paternity Established?
[ ] Yes (check how) [ ] No
[ ] By order
b. Address
[ ] By voluntary acknowledgment
[ ] By adoption
[ ] By conclusive marital presumption
[ ] Other:
c. Social Security Number g. Support Order Established?
[ ] Yes [ ] No
d. Sex e. Date of Birth h. Living with Petitioner?
[ ] Yes [ ] No
B. The child(ren) began residing in ___________________________ on ____________________________.
State Month/Year
VI. Medical Insurance [ ] See Section X
1. [ ] Yes [ ] No
Is obligor required by a child support order to provide medical insurance for the child(ren)?
2. Is obligor required by a child support order to provide medical insurance for the obligee? [ ] Yes [ ] No
3. Medical coverage for dependent child(ren) listed in Section V and/or the obligee is provided by:
For dependent
child(ren) For obligee Obligee’s Insurance Company:
Obligee [ ] [ ]
Obligor [ ] [ ] Policy Number:
State Medicaid [ ] [ ]
Obligor’s Insurance Company:
Obligee’s Employer [ ] [ ]
Obligor’s Employer [ ] [ ] Policy Number:
Other _________________ [ ] [ ]
Other Insurance Company:
Unknown [ ] [ ]
Policy Number:
No Coverage [ ] [ ]
4. The monthly cost paid by the obligee for medical insurance for the obligor’s child(ren) only is: $____________________
(If medical insurance is provided by the obligee or obligee’s employer, skip to number 6).
5. Obligee can purchase needed medical insurance at a monthly cost of: $____________________
6. Were the children ever covered by medical insurance provided by the obligor/obligee, or his/her current employer?
[ ] Yes [ ] No [ ] Unknown
7. Do any of the obligor’s children have special needs or extraordinary medical expenses not covered by insurance?
[ ] Yes [ ] No
(If “Yes”, please indicate the child involved and the type of special needs/extraordinary medical expenses and the related costs. Attach proof.)
8. Is the obligee asking to be reimbursed for medical coverage by obligor? [ ] Yes [ ] No [ ] Unknown
General Testimony Page 5 of 10
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GENERAL TESTIMONY, PAGE 6 Initiating IV-D Case Number
VII. Support Order and Payment Information [ ] See Section X
1. Does a support order exist? (If “No”, skip to page 7.) [ ] Yes [ ] No
2. Did child(ren) reside with the obligor at anytime during the period for which support is sought, except during
periods of visitation specified by a tribunal’s order? [ ] Yes [ ] No If “Yes”, Identify Period of Residency:
From: Thru:
3. If a modification is being requested, indicate the basis for the request below:
[ ] The earnings of the obligor have substantially increased or decreased.
[ ] The earnings of the obligee have substantially increased or decreased.
[ ] The needs of a party or of the child(ren) have substantially increased or decreased.
[ ] Other, Explain ______________________________________________________________________________
4. Describe all current support orders (include all pertinent orders and modifications). NOTE: if more than three (3)
orders exist, attach complete description as below for each.
Date of Order Current Amount Per Month/Week/etc. Toward Arrears Per Month/Week/etc.
$ $
Unpaid Interest $ as of (date) Total Arrears $ as of (date)
Tribunal’s Name & Address
Date of Order Current Amount Per Month/Week/etc. Toward Arrears Per Month/Week/etc.
$ $
Unpaid Interest $ as of (date) Total Arrears $ as of (date)
Tribunal’s Name & Address
Date of Order Current Amount Per Month/Week/etc. Toward Arrears Per Month/Week/etc.
$ $
Unpaid Interest $ as of (date) Total Arrears $ as of (date)
Tribunal’s Name & Address
5. Unpaid Medical Cost Reimbursement $____________________ as of _________________________
(attach documentation) Date
6. Other Unpaid Costs and Fees $____________________ as of _________________________
Date
Explain: ______________________________________________________________________________________________
7. Direct Payments to Obligee: [ ] Affidavit from Obligee Attached [ ] No Direct Payments Received
8. Obligor’s support payment history:
[ ] Certified copy of tribunal/agency payment [ ] Payment history provided on page 6a. [ ] N.A.; responding State does not require.
history is attached. (Skip to page 7). (Skip to page 7).
From (Year) to (Year): Agency Which Prepared Audit/Payment History:
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GENERAL TESTIMONY, PAGE 6a Initiating IV-D Case Number
Obligor’s Payment History Adjudicated Arrears $____________________ as of ____________________
Date of Order
Year: ______________________ Year: ______________________
Amount Due Amount Paid Balance Amount Due Amount Paid Balance
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Total
Year: ______________________ Year: ______________________
Amount Due Amount Paid Balance Amount Due Amount Paid Balance
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Total
Total of Adjudicated and Accrued Arrears $_____________________ as of ___________________________
________________________ ______________________________________________________________________________
Date Name/Title, Agency or Tribunal Signature
________________________ ______________________________________________________________________________
Sworn to and Signed before me Notary Public Official and Title Commission Expires
this Date, County, State
General Testimony Page 6a of 10
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GENERAL TESTIMONY, PAGE 7 Initiating IV-D Case Number
VIII. TANF / Foster Care/Medical Assistance Status [ ] See Section X
[If no TANF/Foster Care/Medical Assistance benefits were paid, skip to Section IX.]
1. Period during which TANF/Foster Care was paid:
From:_______________/__________ To:_______________/__________by:____________________________
First month year Last month year State
2. Total amount of TANF/Foster Care 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, part time $_______________ $________________ $________________
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 $_______________ $________________ $________________
b) State Income Tax $_______________ $________________ $________________
c) Local Tax $_______________ $________________ $________________
d) F.I.C.A. $_______________ $________________ $________________
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GENERAL TESTIMONY, PAGE 8 Initiating IV-D Case Number
Petitioner Current Spouse/Partner Obligor’s Dependent(s)
5. Adjusted Net Monthly $_______________ $________________ $________________
(lines “3” minus lines “4a through 4d”)
6. Other Deductions
a) Savings $_______________ $________________ $________________
b) Loan Repayment $_______________ $________________ $________________
c) Mandatory Retirement $_______________ $________________ $________________
d) Non-mandatory Retirement $_______________ $________________ $________________
e) Medical Insurance $_______________ $________________ $________________
f) Union Dues $_______________ $________________ $________________
g) Other (specify) $_______________ $________________ $________________
7. Net Monthly Income
(line 5 minus lines “6a through 6g”) $________________ $________________ $_________________
8. Gross Income Prior Year $________________ $________________ $________________
Attach three most recent pay stubs from each current employer for all parties shown.
B. Monthly Expenses Petitioner Obligor’s Dependents
1) Rent/Mortgage $__________ $__________
2) Homeowners/Renters Insurance $__________ $__________
3) Home Maintenance & Repair $__________ $__________
4) Heat $__________ $__________
5) Electricity/Gas $__________ $__________
6) Telephone $__________ $__________
7) Water/Sewer $__________ $__________
8) Food $__________ $__________
9) Laundry/Cleaning $__________ $__________
10)Clothing $__________ $__________
11) Life Insurance $__________ $__________
12) Medical Insurance $__________ $__________
13) Uninsured Extraordinary Medical
(attach documentation) $__________ $__________
14) Other Uninsured Health-Related Expenses $__________ $__________
15) Auto Payment $__________ $__________
16) Auto Insurance $__________ $__________
17) Auto Expenses $__________ $__________
18) Other Transportation $__________ $__________
19) Child Care $__________ $__________
Provider:__________________________
Frequency_____________Per ________
20) Support Payments, actual amount paid $__________ $__________
21) Internet service $__________ $__________
22) Other; Explain $__________ $__________
(lines 1 through 22) $__________ $__________
Total Monthly Expenses
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GENERAL TESTIMONY, PAGE 9 Initiating IV-D Case Number
C. Assets:
1) Real Estate ____________________________________________________________________
Address
____________________________________________________________________
Owner(s)
____________________________________________________________________
Title
$__________________________ minus $_________________________ = $_________________
Assessed Value Mortgage(s)
2) IRA, Keogh, Pension, Profit Sharing, Other Retirement Plans
_______________________________________________________________________________
$_________________
Institution or Plan Name and Account Number
_______________________________________________________________________________
$_________________
Institution or Plan Name and Account Number
3) Tax Deferred Annuity Plan(s)
$_________________
4) Life Insurance: Present Cash Value
$_________________
5) Savings & Checking Accounts, Money Market Accounts, & CDs
_______________________________________________________________________________$_________________
Institution Name and Account Number
_______________________________________________________________________________
$_________________
Institution Name and Account Number
6) Automobiles/Vehicles
_______________ _______________ __________ $_____________ minus $____________ = $_____________
Make Model Year Estimated Value Loan Balance
_______________ _______________ __________ $_____________ minus $____________ = $_____________
Make Model Year Estimated Value Loan Balance
_______________ _______________ __________ $_____________ minus $____________ = $_____________
Make Model Year Estimated Value Loan Balance
7) Other (e.g., Personal Property, Securities, etc). Describe: __________________ $_____________
Total Assets (lines 1 through 7) $_____________
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GENERAL TESTIMONY, PAGE 10 Initiating IV-D Case Number
X. Other Pertinent Information (Attach additional sheets if necessary).
XI. Verification
[ ] Attached are the required number of copies of all support orders for the case.
Also attached and incorporated by reference are:
[ ] Copy of the certified child support payment records.
[ ] Copies of three most recent pay stubs from current employer.
[ ] Copies of bills for prenatal, postnatal and general health care of mother and child.
[ ] Assignment or subrogation of support rights.
[ ] “Affidavit in Support of Establishing Paternity” for each child whose paternity is at issue.
[ ] Copy of child(ren)’s birth certificate(s).
[ ] Acknowledgment of parentage.
[ ] Documentation of legal custody/guardianship of child(ren).
[ ] Documentation that children are in foster care.
[ ] Other:________________________________________________________________________________________
All of the information and facts contained in this General Testimony are true and correct to my/our best knowledge
and belief.
______________________ _________________________________________ _____________________________
Date Petitioner (Name/Title) Signature
______________________ _________________________________________ _____________________________
Date Agency Representative (Name/Title) Signature
______________________ _________________________________________ _____________________________
Sworn to and Signed Before me Notary Public, Tribunal/Agency Commission Expires
This Date County/State Official and Title
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