Fill and Sign the Full Text of Ampquotdocuments and Records Relating to the State Form

T H E S T A TE O F N EW H AM PSH IR E SU PE R IO R C O URT C ou nty I n t h e m atte r o f P E TIT IO N F O R C UST O DY A ND S U PPO RT 1.Y ou r N am e2.C hild (re n )’s F ath er’s N am eDate o f B ir thR esid en ce A ddre ssT ow n/C ityC ou ntyS ta te3 .C hild (re n )’s M oth er’s N am eDate o f B ir thR esid en ce A ddre ssT ow n/C ityC ou ntyS ta te4 .Y ou h av e b een a r e sid en t o f N ew H am psh ir e s in ce5 .C hild (re n ) w ho a re t h e s u bje ct o f t h is p etitio n:N AM EDATE O F B IR THA DD RESS6.T he c h il d (re n ) h av e r e sid ed i n N ew H am psh ir e s in ce7 .A re t h e p are n ts o f t h ese c h ild re n m arrie d t o e ach o th er? Y esN o 8.P le ase c h eck o ne o f t h e f o llo w in g r e g ard in g p ublic a ssis ta n ce:N o p ublic a ssis ta n ce ( A FD C/T A NF) is n ow b ein g o r h as w ith in th e la st 6 m onth s b een p ro vid ed , no r is med ic al assis ta n ce (M ed ic aid ) pre se n tly bein g pro vid ed , fo r an y m in or ch ild lis te d i n p ara g ra p h 5 .T he N .H . D ep artm en t o f H ealth a n d H um an S erv ic es i s p ro vid in g o r h as p ro vid ed w ith in t h e l a st 6 mo nth s p ublic a ssis ta n ce (A FD C/T A NF) a n d/o r m ed ic a l a ssis ta n ce (M ed ic aid ) fo r a n y min or c h ild . I f t h is i s c h eck ed , y ou m ust m ail c o pie s o f t h is p etitio n a n d t h e p ers o nal d ata sh eet t o t h e D ep artm en t a t: O CS L eg al O ffic e 6 H azen D riv e C onco rd , N H 0 3301 C ase N o.T o b e g iv en b y c o urt9 .B y f ilin g t h is p etitio n, y ou a re a sk in g t h at t h e C ourt ( p le ase c h eck e ach r e q uest t h at a p plie s):A . I s su e o rd ers c o ncern in g c u sto dy a n d v is ita tio n. SU -W W W-0 05 ( 4 /9 8)B . I s su e o rd ers c o ncern in g s u pport a n d h ealth i n su ra n ce.C . G ra n t a n y o th er o rd ers w hic h m ay b e a p pro pria te .1 0.T em pora ry O rd ers, i f i s su ed , a re i n e ffe ct u ntil t h e f in al o rd ers ;C heck h ere if y ou w is h th e co u rt to is su e te m pora ry o rd ers co ncern in g th e cu sto dy, vi s ita tio n, su pport, h ealth in su ra n ce, a n d o th er m atte rs re la tin g to th e ch ild (re n ) l is te d i n p ara g ra p h 5 . _ __ ____ _______ ______________ ______ _________________________________________D ate Sig natu re (S ig n in fro nt of N ota ry P ublic or Ju stic e of th e P eace) __________________________________________ A tto rn ey ( if a n y)_________________________________________A tto rn ey ’s a d dre ss S ta te o f N ew H am psh ir e_ __ ____ _______ _________ C oun ty T he p ers o n s ig nin g th is p etitio n a p peare d a n d s ig ned th is b efo re m e a n d to ok o ath th at th e f a cts s ta te d in th is p etitio n a re tr u e, to t h e b est o f h is o r h er k now le d ge a n d b elie f, a n d t h at h e/s h e h as m aile d t h e c o pie s o f t h is p etitio n a n d t h e p ers o nal d ata s h eet to O CS ( if r e q uir e d u nder p ara g ra p h 8 ). ________________________________________D ate Nota ry P ublic /J u stic e o f t h e P eace SU -W W W-0 05 ( 4 /9 8)