Fill and Sign the New Hampshire Custody 497318774 Form

THE STATE OF NEW HAMPSHIRE SUPERIOR COURT County In the matter of PETITION FOR CUSTODY AND SUPPORT 1. Your Name 2. Child(ren)’s Father’s Name Date of Birth Residence Address Town/City County State 3. Child(ren)’s Mother’s Name Date of Birth Residence Address Town/City County State 4. You have been a resident of New Hampshire since 5. Child(ren) who are the subject of this petition: NAME DATE OF BIRTH ADDRESS 6. The child(ren) have resided in New Hampshire since 7. Are the parents of these children married to each other? Yes No 8. Please check one of the following regarding public assistance: No public assistance (AFDC/TANF) is now being or has within the last 6 months been provided, nor is medical assistance (Medicaid) presently being provided, for any minor child listed in paragraph 5. The N.H. Department of Health and Human Services is providing or has provided within the last 6 months public assistance (AFDC/TANF) and/or medical assistance (Medicaid) for any minor child. If this is checked, you must mail copies of this petition and the personal data sheet to the Department at: OCS Legal Office 6 Hazen Drive Concord, NH 03301 Case No. To be given by court 9. By filing this petition, you are asking that the Court (please check each request that applies): A. Issue orders concerning custody and visitation. B. Issue orders concerning support and health insurance. C. Grant any other orders which may be appropriate. 10. Temporary Orders , if issued, are in effect until the final orders; Check here if you wish the court to issue temporary orders concerning the custody, visitation, support, health insurance, and other matters relating to the child(ren) listed in paragraph 5. __________________________________ _________________________________________ Date Signature (Sign in front of Notary Public or Justice of the Peace) __________________________________________ Attorney (if any) _________________________________________ Attorney’s address State of New Hampshire _______________________ County The person signing this petition appeared and signed this before me and took oath that the facts stated in this petition are true, to the best of his or her knowledge and belief, and that he/she has mailed the copies of this petition and the personal data sheet to OCS (if required under paragraph 8). ________________________________________ Date Notary Public/Justice of the Peace SU-WWW-005 (4/98)