Fill and Sign the Montana Department of Public Health and Human Services Child Support Enforcement Division Form

Notice to CSED, Page 1 of 2 Approved by the Montana Supreme Court Commission on Self-Represented Litigants and Montana Legal Services Association, 7/24/02 _______________________________ Name _____________________________________ Address _____________________________________ City State Zip Code _____________________________________ Phone Number PETITIONER PRO SE MONTANA _______________ JUDICIAL DISTRICT COURT _____________________ COUNTY In re the Marriage of: ________________________, Petitioner, and ________________________, Respondent.Cause No.: _________________ Notice and Acknowledgment to Child Support Enforcement Division COMES NOW, the Petitioner, _____________________, and gives notice to the State of Montana, Department of Public Health and Human Services, Child Support Enforcement Division, in accordance with M.C.A. § 40-5-202(5), that s/he has filed a Petition for Dissolution of Marriage in the above-entitled action, and that one of the issues in this legal action is child support. A copy of the Petition is attached hereto. In accordance with M.R.Civ.P. 4D(2)(h), the Petitioner also gives notice to the Attorney General of the State of Montana. DATED this ______ day of ____________________, 20___. ____________________________________ Petitioner Pro Se ____________________________________ Print Name Notice to CSED, Page 2 of 2 Approved by the Montana Supreme Court Commission on Self-Represented Litigants and Montana Legal Services Association, 7/24/02 CERTIFICATE OF SERVICE I hereby certify that a copy of the foregoing Notice and Petition for Dissolution were served upo n t he fo llo w ing by mailing t rue and co rrect co pies o n t he ____ day of ________________, 20____, postage prepaid and addressed as follows: Department of Public Health and Human Services Attorney General Child Support Enforcement Division 215 N. Sanders, Third Floor P.O. Box 201401 Helena, Montana 59620-1401 DATED this ______ day of ____________________, 20___. ____________________________________ Petitioner Pro Se ACKNOWLEDGMENT OF SERVICE OF NOTICE I, the undersigned, hereby acknowledge that I received a copy of the Petitioner’s Notice to Child Support Enforcement Division and a copy of the Petition in the above-entitled action. DATED this _____ day of __________________________, 20___. By: _________________________________ DECLINATION BY DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES The Department of Public Health and Human Services declines to enter this proceeding as a party. DATED this _____ day of ____________________________, 20_____. By: DPHHS, Child Support Enforcement Division