Fill and Sign the This Petition Will Affect Minor Children Complete 3 4 and 5 below Otherwise Move to 6 Form

THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH Court Name: Case Name: Case Number: (if known) PETITION FOR 1. Petitioner Name Date of Birth E-mail address Residence Address Mailing Address (if different) Telephone Number (Home) (W ork) 2. Respondent Name Date of Birth E-mail address Residence Address Mailing Address (if different) Telephone Number (Home) (W ork) If this petition will affect minor children, complete #3, 4, and 5 below, otherwise move to #6. 3. List any minor children to be affected by this petition: 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 any minor child listed above. 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 listed above. 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 NHJB-2277-FS (12/15/2006) Page 1 of 2 Case Name: Case Number: PETITION FOR 5.   Are there any pending adoption, juvenile, domestic violence, domestic relations, paternity, legitimation, custody, parental rights and responsibilities, or other proceedings in any court in any state affecting any child(ren) named in this petition or parents of those children? Yes No I f ye s, sp ecif y 6.   What orders do you want the court to make? Date   Signature of Petitioner (Sign in front of Notarial Officer) A tt o rn e y (if an y) A tt o rn e y's Addre ss State of , County of This instrument was acknowledged before me on by My Commission Expires Affix Seal, if any Signature of Notarial Officer / Title NHJB-2277-FS (12/15/2006)   Page 2 of 2