Fill and Sign the No Agreement Form

NHJB-2062-F (04/11/2014) Page 1 of 4 THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: PETITION TO CHANGE COURT ORDER No agreement Agreement 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 Current Address If there are minor children born to or adopted by the parties, complete questions 4 – 8. This information is required under RSA 458-A, the Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA). It is important that you answer these questions with as much detail and accuracy as possible. Lack of adequate information could significantly delay orders being issued in your case. There are several situations that might result in New Hampshire exercising jurisdiction over child/ren. The continuous presence of the child/ren in New Hampshire for six (6) months is not the only basis for jurisdiction. In some emergency situations, the court may be able to exercise jurisdiction on a temporary basis. Case Name: Case Number: PETITION TO CHANGE COURT ORDER NHJB-2062-F (04/11/2014) Page 2 of 4 4. List the places where the minor child/ren of the parties has/have lived in the last five (5) years and the names of the people they lived with at that time, if you know. Start with where the child lives now and work backward in time. Dates From/To Town/City, State Parent(s)/Care taker Current Address/Contact Address of Parent/Caretaker Which Child/ren If more space is needed, attach Ex tra Page (Form NHJB-2656-FPS). I have attached Form NHJB-2656-FPS because additional space was needed. 5. Are there any person(s), not a party to this proce eding, who have physical custody of the child/ren or who claim to have custody, physical custody or parenting time rights? Yes No If yes, list name(s) and address(es) of person(s): 6. Check one of the following: I have not participated in any court case(s) concerning the custody, visitation, parenting time or placement of the child/ren in this or any other state. OR I have participated in court case(s) concerning the custody, visitation, parenting time or placement of the child/ren in this or any other state. I have participated in the following: Name of Court State Case No. Date of Court Order 7. Are there any actions for enforcement, or proceedings relating to domestic violence, domestic relations, protective orders, marriage dissolution, paternity, legitimation, custody, parental rights and responsibilities, termination of parental rights, adoption, juvenile, or ot her proceedings in any court in any state affecting any children named in this petition or parents of those children? Yes No If yes, complete the following: Name of Court State Case No. Type of Court Case Case Name: Case Number: PETITION TO CHANGE COURT ORDER NHJB-2062-F (04/11/2014) Page 3 of 4 8. Optional: I am alleging, under oath, that my or my child/ren’s health, safety, or liberty would be jeopardized by the disclosure of identifying information set forth in this Petition. To support my allegation, I state as follows: 9. What part of the court order(s) do you want the court to change? (Check any that apply) The date of the most recent court order (if known): Child Support Only Child Support and Parenting Plan Legal Separation to Divorce Alimony Parenting Plan Other 10. I have tried to resolve the issue(s) raised in this petition with the other party. We are unable to resolve the issue(s) and have sought the help of a neutral thir d party (such as a mediator or neutral evaluator) to assist us. We are unable to work out the disagreement after seeking third party assistance. OR I have not tried to resolve the issue(s) raised in this petition because: a. There is a domestic violence protective order in effect OR b. Other (State reasons you did not try to resolve issue(s) with other party): 11. What, specifically, do you want the court to order? (Please attach additional page(s) if necessary.) 12. Why should the court change the current orders? (List each reason separately.) 13. 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 pr ovided, for any minor child of the parties. The N. H. Department of Health and Human Services is providing or has provided within the last 6 months public assistance (TANF) and/or medical assistance (Medicaid) for a minor child or children of the parties. If you check this box, you must mail c opies of this petition and the Personal Data Sheet (NHJB-2077-FS) 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 TO CHANGE COURT ORDER NHJB-2062-F (04/11/2014) Page 4 of 4 14. By filing this petition, you are asking that the Court: Change the current orders as stated above; Schedule a hearing; Other: Grant any other orders which may be appropriate. I acknowledge that I have a continuing duty to inform the court of any court action in this or any other state that could affect the child/ren in this case. I swear or affirm that the foregoing information is true and correct to the best of my knowledge. Date Signature of Party Filing Petition to Change Court Order 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 Signature of Attorney Printed Name, Address and Phone Number of Attorney Bar #