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Free New Jersey Child Custody Form - PDF Form Download

New Jersey Child Custody Form Overall rating: ☆☆☆☆☆ 0 based on 0 reviews
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Use this template/form to file for child custody in the state of New Jersey


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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

General Testimony Page 3 of 10

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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:

General Testimony Page 6 of 10

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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. $_______________ $________________ $________________

General Testimony Page 7 of 10

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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

General Testimony Page 8 of 10

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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) $_____________

General Testimony Page 9 of 10

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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

General Testimony Page 10 of 10

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