Fill and Sign the Topicality Grammatical Tense Insurance Form

SU-WWW-010 (4/98) THE STATE OF NEW HAMPSHIRE SUPERIOR COURT ______________ County In the matter of ___________________________________________ PETITION FOR PATERNITY 1.Your Name ___________________________________________________________________2. Child(ren)’s Father’s Name_____________________________Date of Birth _______________ Residence Address _____________________________________________________________ Town/City CountyState 3.Child(ren)’s Mother’s Name_____________________________Date of Birth______________ Residence Address _____________________________________________________________ Town/City CountyState 4.You have been a resident of New Hampshire since ___________________________________5.Child(ren) whose paternity is to be established:NAME DATE OF BIRTH ADDRESS________________________________________________________________________________________________________________________________________________________6.The children have resided in New Hampshire since _________________________________7. State the name of the father, if any, listed on each child’s birth certificate_____________________________________________________________________________________________8.Was the mother married at the time of, or within 10 months before the birth of any child listed in paragraph 5?[ ] Yes [ ] No 9.If your answer to Paragraph 8 was Yes, fill in name and address of her spouse or former spouse: 10.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: Case Number_____________To be assigned by Court SU-WWW-010 (4/98) OCS Legal Office6 Hazen Drive Concord, NH 03301 11. By filing this petition, you are asking that the Court: A. Find that the man listed above is the father of the children listed in paragraph 5, and enter his name on each child’s birth certificate;B. [ ]Check here if you wish the court to issue orders concerning the custody, visitation, support, health insurance, and other matters relating to the minor children; C.Grant any other orders which may be appropriate. 12.Temporary Orders, if issued, are in effect until the final orders are granted.[ ]Check here if you wish the court to issue temporary orders concerning the custody, visitation, support, health insurance, and other matters relating to the children listed in paragraph 5.__________________________________ _______________________________________DateSignature (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 10). ________________________________________DateNotary Public/Justice of the Peace