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NHJB-2199-F (04/09/2009) Page 1 of 2 THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) PETITION FOR CONTEMPT 1. Your Name Date of Birth E-mail address (optional) Residence Address Mailing Address (if different) Telephone Number (Home) (Work) 2. Other Party’s Name Date of Birth E-mail address (optional) Residence Address Mailing Address (if different) Telephone Number (Home) (Work) 3. List minor children born to or adopted by the parties: Name Date of Birth Name Date of Birth 4. Please check one of the following regarding public assistance: No public assistance (TANF) is now being or has within the last 6 months been provided, nor is medical assistance (Medicaid) presently being provided for the minor children of the parties. The NH Department of Health and Human Servic es is providing or has provided within the last 6 months public assistance (TANF) and/o r medical assistance (Medicaid) for any minor children of the parties. If you check this box, you must mail copies of this petition and the personal data sheet to DHHS at: New Hampshire Department of Health and Human Services Division of Child Support Services - Legal Unit 129 Pleasant Street Concord, NH 03301 Case Name: Case Number: PETITION FOR CONTEMPT NHJB-2199-F (04/09/2009) Page 2 of 2 5. What order(s) is/are not being followed? Date(s) (if known) of the court orde r(s) which is/are not being followed: How is/are the order(s) not being followed? (Please attach additional page(s) if necessary.) 6. By filing this petition, you are asking the Court to hold the other party in contempt and order the other party to immediately obey t he orders referred to in this Petition. The Court will schedule a hearing on your request. OTHER REQUESTS: A. Order the other party to pay atto rney's fees (if you have an attorney). B. Order the other party to pay the filing fees. C. Other (be specific). D. Grant any other order s which may be appropriate. Date Signature of Person Filing Petition (Sign in front of Notarial Officer) Printed Name of Person Filing Petition Attorney (if any) Bar # Attorney's Address State of , County of This instrument was acknowledged bef ore me on by My Commission Expires Affix Seal, if any Signature of Notarial Officer / Title