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CHILD AND SPOUSAL SUPPORT

Would you like to request Child Support?

% of time Children spent with you:

% of time Children spent with Other Parent:

If not sure, explain here:

Do you have health insurance available to you for the children through your job?

If so, please fill out the following:

Name of Insurance Company:

Monthly Cost: $

Address:

Are/have you and him/her:

Would you like to have physical/legal custody of child(ren)

if not, please mention who should have custody:

Other information:

ADDITIONAL EXPENSES FOR THE CHILDREN IN THIS CASE

Childcare so you can work or get trained: $

Children’s healthcare not covered by insurance: $

Travel Expenses for Visitation: $

Children’s education or other special needs: $

SPECIAL HARDSHIPS

Hardship

Extraordinary health expenses

Major losses not covered by insurance (fire, theft, etc.)

Expenses for minors who are from other relationships and living with me

Monthly $

For # of Months

Minor's Name

Age

If the Expenses above create an extreme financial hardship, explain why:

SPOUSAL SUPPORT

Would you like to ask for Spousal Support?

Summons

Civil Restraining Orders

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