New York > Statewide > Family Court > Uniform Interstate Family Support Act
General Testimony UIFSA-5 - New York
| General Testimony Form. This is a New York form and can be used in Uniform Interstate Family Support Act Family Court Statewide . |
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GENERAL TESTIMONY Petitioner Respondent [ ] IV-D Non Public Assistance [ ] IV-D Non PA Medicaid [ ] Full Services [ ] Medical Services Only [ ] IV-D Public Assistance [ ] IV-E Foster Care (IV-D Case) [ ] Non IV-D File Stamp Responding IV-D Case No. __________________________________ Responding Docket No. _____________________________________ Initiating IV-D Case No. __________________________________ Initiating Docket No. _____________________________________ Petitioner is: [ ] Obligee [ ] Obligor [ ] Obligee [ ] Obligor Name (First, Middle, Last) [ ] Caretaker Other than Parent [ ] Foster Care [ ] Caretaker Other than Parent [ ] Foster Care Respondent is: ___________________________________________________ being duly sworn, under penalties of perjury, testifies as follows: I. Personal Information About Child(ren)'s Mother [ ] See Section X A.1. Mother is: 3. Full Name [ ] Obligee [ ] Obligor 2. [ ] Nondisclosure Finding Attached 6. Date of Birth 8. Work Phone ( ) (First, Mid, Last; include nickname, alias) Confirmed______________(date) 4. Home Address [ ] 5. Social Security Number 7. Home 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 $ 13. Real or Personal Property (type & location) 12. Other Monthly Income (& source) $ B. Physical Description of Child(ren)'s Mother (Optional: 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 [ ] Married 4. [ ] Divorced 1. General Testimony [ ] Single 5. [ ] Legally Separated 2. [ ] Living with Non-Marital Partner 6. [ ] Separated 7. [ ] Unknown 3. OMB No. 0970 - 0085 Page 1 of 10 2001 © American LegalNet, Inc. GENERAL TESTIMONY, PAGE 2 D. Information about Current Spouse or Partner of Child(ren)'s Mother 1. Name of New Spouse or Non-Marital Partner (First, Mid, Last) Initiating IV-D Case No. 2. Is Current Spouse/Partner Employed? [ ] Yes [ ] No 3. Name and Address of Spouse's/Partner's Employer [ ] Unknown 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 1. a. Full Name (First, Mid, Last) (If yes, provide information below.) b. Date of Birth d. Living With: f. Monthly Amount; Gross: b. Date of Birth d. Living With: f. Monthly Amount; Gross: b. Date of Birth d. Living With: f. Monthly Amount; Gross: Net: Net: Net: c. Relationship e. Source of Support/Income 2. a. Full Name (First, Mid, Last) c. Relationship e. Source of Support/Income 3. a. Full Name (First, Mid, Last) c. Relationship e. Source of Support/Income II. Personal Information About Child(ren)'s Father A.1. Father is: 3. Full Name [ ] See Section X [ ] Obligee [ ] Obligor 2. [ ] Nondisclosure Finding Attached 6. Date of Birth 8. Work Phone ( ) (First, Mid, Last; include nickname, alias) Confirmed____________(date) 4. Home Address [ ] 5. Social Security Number 7. Home 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 $ 13. Real or Personal Property (type & location) 12. Other Monthly Income (& source) $ B. Physical Description of Child(ren)'s Father (Optional: Attach photo if available.) 1. Race 2. Height 3. Weight 4. Hair Color 5. Eye Color General Testimony Page 2 of 10 2001 © American LegalNet, Inc. GENERAL TESTIMONY, PAGE 3 C. Present Marital Status of Child(ren)'s Father Initiating IV-D Case No. [ ] Married 4. [ ] Divorced 1. [ ] Single 5. [ ] Legally Separated 2. [ ] Living with Non-Marital Partner 6. [ ] Separated 7. [ ] Unknown 3. 2. Is Current Spouse/Partner Employed? D. Information about Current Spouse or Partner of Child(ren)'s Father 1. Name of New Spouse or Non-Marital Partner (First, Mid, Last) [ ] Yes [ ] No 3. Name and Address of Spouse's/Partner's Employer [ ] Unknown 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 1. a. Full Name (First, Mid, Last) (If yes, provide information below.) b. Date of Birth d. Living With: f. Monthly Amount; Gross: b. Date of Birth d. Living With: f. Monthly Amount; Gross: Net: Net: c. Relationship e. Source of Support/Income 2. a. Full Name (First, Mid, Last) c. Relationship e. Source of Support/Income 3. a. Full Name (First, Mid, Last) b. Date of Birth d. Living With: f. Monthly Amount; Gross: Net: c. Relationship e. Source of Support/Income III. Personal Information About Caretaker Other than Parent 1. Caretaker's Relation to Child is: 3. Full Name (First, Mid, Last; include nickname, alias) Confirmed____________(date) [ ] See Section X 2. [ ] Nondisclosure Finding Attached 6. Date of Birth 9. Work Phone ( ) 7. Sex 4. Home Address [ ] 5. Social Security Number 8. Home 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 $ 14. Date Child(ren) Began Residing With Caretaker 13. Other Monthly Income (& source) $ General Testimony Page 3 of 10 2001 © American LegalNet, Inc. GENERAL TESTIMONY, PAGE 4 Initiating IV-D Case No. IV. Legal Relationship of Parents 1. 3. 4. 6. 7. 9. [ ] See Section X County/State [ ] Never married to each other [ ] Separated on _______________ Date 2. [ ] Married on _______________________in ______________________________ Date Dates County/State [ ] Married by common law for the period __________________________in_____________________________________ 5. [ ] Divorced on ________________in_____________________________ Date County/State County/State [ ] Legally separated on___________________in________________________________ Date [ ] Divorce pending in________________________________ County/State 8. [ ] Support Order Entered on ____________________ Date [ ] No support order 10. [ ] Other______________________________________________________________ 11. Tribunal & Location (Divorce, Legal Separation, Support Order): V. Dependent Child(ren) in this Action A. List obligor's (named on page 1 of this form) child(ren) only. 1. a. Full Name b. Address (First, Mid, Last) [ ] See Section X [ ] Nondisclosure Finding Attached f. Paternity Established? [ ] Yes [ ] Ye
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