§ Rule 1910.27 Form of Complaint Order Income Statements and Expense Statements Health Insurance Coverage Information Form Form of Support Order Form Petition for Modification

Rule 1910.27. Form of Complaint. Order. Income Statements and Expense Statements. Health Insurance Coverage Information Form. Form of Support Order. Form Petition for Modification

(a) The complaint in an action for support shall be substantially in the following form:

(Caption)

COMPLAINT FOR SUPPORT

1. Plaintiff resides at ______(Street), ______(City),
______(Zip Code), __________ County. Plaintiff's Social Security Number is __________, and date of birth is _________.
Number is __________________, and date of birth is __________.

2. Defendant resides at ______(Street), ______(City), ______(Zip Code), __________ County. Defendant's Social Security Number is __________, and date of birth is __________.

3. (a) Plaintiff and Defendant were married on ______(Date), at ______(City and State).

(b) Plaintiff and Defendant were separated on ______(Date).

Date

4. Plaintiff and Defendant are the parents of the following children:

(a) Born of the Marriage:

Name Birth Date Age Residence

______________________ __________________ ___________ ______________________

(b) Born out of Wedlock:

Name Birth Date Age Residence

______________________ __________________ ___________ ______________________

5. Plaintiff seeks support for the following persons:

_________________________________________________________________________________________________________________________________________________________.

6. (a) Plaintiff is (not) receiving public assistance in the amount of $__________ per __________ for the support of ______(Name(s)).

(b) Plaintiff is receiving additional income in the amount of $__________________ from ______(Name(s)).

7. A previous support order was entered against the defendant on ____(Date) in an action at ______(Court, term and docket number) in the amount of $________ for the support of _____(Name(s))

There are (no) arrearages in the amount of $__________. The order has (not) been terminated.

8. Plaintiff last received support from the Defendant in the amount of $__________ on ______(Date). WHEREFORE, Plaintiff requests that an order be entered against Defendant and in favor of the Plaintiff and the aforementioned child(ren) for reasonable support and medical coverage.

I verify that the statements made in this Complaint are true and correct, I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. § 4904, relating to unsworn falsification to authorities.

______________________________________

Plaintiff

NOTICE

Guidelines for child and spousal support, and for alimony pendente lite have been prepared by the court of common pleas and are available for inspection in the office of the Domestic

'Relations Section, ____________________. (Address)

(b) The order to be attached at the front of the complaint set forth in subdivision (a) shall be in substantially the following form:

(Caption)

ORDER OF COURT

You, __________, defendant, are ordered to appear at __________ before __________, a conference officer of the Domestic Relations Section, on the ___ day of ______, 20__, at __________.M., for a conference, after which the officer may recommend that an order for support be entered against you.

You are further ordered to bring to the conference

(1) a true copy of your most recent Federal Income Tax Return, including W-2s, as filed,

(2) your pay stubs for the preceding six months,

(3) the Income Statement and the appropriate Expense Statement, if required, attached to this order, completed as required by Rule 1910.11(c),

(4) verification of child care expenses, and

(5) proof of medical coverage which you may have, or may have available to you.

If you fail to appear for the conference or to bring the required documents, the court may issue a warrant for your arrest and/or enter an interim support order. If paternity is an issue, the court shall enter an order establishing paternity.

THE APPROPRIATE COURT OFFICER MAY ENTER AN ORDER AGAINST EITHER PARTY BASED UPON THE EVIDENCE PRESENTED WITHOUT REGARD TO WHICH PARTY INITIATED THE SUPPORT ACTION.

Date of Order: ______________________________________ ______________________________________

IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE.

_____________________________

(Name)

_____________________________

(Address)

_____________________________

(Telephone Number)

AMERICANS WITH DISABILITIES ACT OF 1990

The Court of Common Pleas of ________________ County is required by law to comply with the Americans with Disabilities Act of 1990. For information about accessible facilities and reasonable accommodations available to disabled individuals having business before the court, please contact our office. All arrangements must be made at least 72 hours prior to any hearing or business before the court. You must attend the scheduled conference or hearing.

(1) Income Statement. This form must be filled out in all cases.

______________________ v. ______________________ No. ______

THIS FORM MUST BE FILLED OUT

(If you are self-employed or if you are salaried by a business of which you are owner in whole or in part, you must also fill out the Supplemental Income Statement which appears below.)

INCOME STATEMENT OF

(Name) (PACSES Number)

I verify that the statements made in this Income Statement are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S.A. § 4904 relating to unsworn falsification to authorities.

Date: ______________________________________ ______________________________________

Plaintiff or Defendant

INCOME

Employer: _____________________________________________________________________________

Address: _____________________________________________________________________________

Type of Work: _____________________________________________________________________________

Payroll Number: _____________________________________________________________________________

Pay Period (weekly, biweekly, etc.):

_____________________________________________________________________________

Gross Pay per Pay Period $_______

Itemized Payroll Deductions:

Federal Withholding $_______

FICA _______

Local Wage Tax _______

State Income Tax _______

Mandatory Retirement _______

Union Dues

_______
_______

_______

Health Insurance _______

Other (specify)

__________________________________ _______

Net Pay per Pay Period: $_______

Other Income:

Week Month Year

(Fill in Appropriate Column)

Interest $_______ $_______ $_______

Dividends _______ _______ _______

Pension Distributions _______ _______ _______

Annuity _______ _______ _______

Social Security _______ _______ _______

Rents _______ _______ _______

Royalties _______ _______ _______

_______ _______ _______

Unemployment Comp. _______ _______ _______

Workers Comp. _______ _______ _______

Employer Fringe Benefits _______ _______ _______

Other

______ _______ _______

Total $_______ $_______ $_______

TOTAL INCOME $_____________________________________

PROPERTY OWNED

Ownership*

Description Value H W J

Checking

accounts ______________ $______________ ___ ___ ___

Savings accounts ______________ ______________ ___ ___ ___

Credit Union ______________ ______________ ___ ___ ___

Stocks/bonds ______________ ______________ ___ ___ ___

Real Estate

Other ______________ ______________ ___ ___ ___

Total $______________

INSURANCE

Coverage*

Company

Policy No.

H W C

Hospital

Blue Cross ______________ ______________ ___ ___ ___

Other ______________ ______________ ___ ___ ___

Medical

Blue Shield ______________ ______________ ___ ___ ___

Other ______________ ______________ ___ ___ ___

Health/Accident ______________ ______________ ___ ___ ___

Disability Income ______________ ______________ ___ ___ ___

Dental ______________ ______________ ___ ___ ___

Other ______________ ______________ ___ ___ ___

* H=Husband; W=Wife; J=Joint; C=Child

SUPPLEMENTAL INCOME STATEMENT

(a) This form is to be filled out by a person (check one):

[ ] (1) who operates a business or practices a profession, or

[ ] (2) who is a member of a partnership or joint venture, or

[ ] (3) who is a shareholder in and is salaried by a closed corporation or similar entity.

(b) Attach to this statement a copy of the following documents relating to the partnership, joint venture, business,
profession, corporation or similar entity:

(1) the most recent Federal Income Tax Return, and

(2) the most recent Profit and Loss Statement.

Address and Telephone Number:

________________________________________________________________________

(d) Nature of business

(check one)

[ ] (1) partnership

[ ] (2) joint venture

[ ] (3) profession

[ ] (4) closed corporation

[ ] (5) other

(e) Name of accountant, controller or other person in charge of financial records:

________________________________________________________________________

(f) Annual income from business:

________________________________________________________________________

(1) How often is income received?

__________________________________________________________________

(2) Gross income per pay period:

__________________________________________________________________

(3) Net income per pay period:

__________________________________________________________________

(4) Specified deductions, if any:

__________________________________________________________________

(2) Expense Statements. An Expense Statement is not required in cases which can be determined pursuant to the guidelines unless a party avers unusual needs and expenses that may warrant a deviation from the guideline amount of support pursuant to Rule 1910.16-5 or seeks an apportionment of expenses pursuant to Rule 1910.16-6. (See Rule 1910.11(c)(1)). Child support is calculated under the guidelines based upon the net incomes of the parties, with additional amounts ordered as necessary to provide for child care expenses, health insurance premiums, unreimbursed medical expenses, mortgage payments and other needs, contingent upon the obligor's ability to pay. The Expense Statement in subparagraph (A) below shall be utilized if a party is claiming that he or she
has unusual needs and unusual fixed expenses that may warrant deviation or adjustment in a case determined under he guidelines. In child support, spousal support and alimony pendente lite cases calculated pursuant to Rule 1910.16-3.1 and in divorce cases involving claims for alimony or counsel fees, costs and expenses pursuant to Rule 1920.31(a), the parties must complete the Expense Statement in subparagraph (B) below.

(A) Guidelines Expense Statement. If the combined monthly net income of the parties is $30,000 or less, it is not necessary to complete this form unless a party is claiming unusual needs and expenses that may warrant a deviation from the guideline amount of support pursuant to Rule 1910.16-5 or seeks an apportionment of expenses pursuant to Rule 1910.16-6. At the conference, each party must provide receipts or other verification of expenses claimed on this statement. The Guidelines Expense Statement shall be substantially in the following form.

EXPENSE STATEMENT OF

(Name) (PACSES Number)

I verify that the statements made in this Expense Statement are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S.A. § 4904 relating to unsworn falsification to authorities.

Date: ______________________________________ ______________________________________

Plaintiff or Defendant

Weekly Monthly Yearly

(Fill in Appropriate Column)

Mortgage (including real estate taxes and

homeowner's insurance) or Rent

$________ $________ $________

Health Insurance Premiums ________ ________ ________

Unreimbursed Medical Expenses:

Doctor ________ ________ ________

Dentist ________ ________ ________

Orthodontist ________ ________ ________

Hospital ________ ________ ________

Medicine ________ ________ ________

Special Needs (glasses, braces, orthopedic therapy)

________ ________ ________

Child Care ________ ________ ________

Private school ________ ________ ________

Parochial school ________ ________ ________

Loans/Debts ________ ________ ________

Support of Other

Dependents:

Other child support ________ ________ ________

Alimony payments ________ ________ ________

Other: (Specify)

________________________________ ________ ________ ________

Total $________ $________ $________

(B) Expense Statement for Cases Pursuant to Rule 1910.16-3.1 and Rule 1920.31. No later than five business days prior to the conference, the parties shall exchange this form, along with receipts or other verification of the expenses set forth on this form. Failure to comply with this provision may result in an appropriate order for sanctions and/or the entry of an interim order based upon the information provided.

EXPENSE STATEMENT OF

(Name) (PACSES Number)

Date: ______________________________________ ______________________________________

Plaintiff or Defendant

EXPENSES MONTHLY

TOTAL

MONTHLY

CHILDREN

MONTHLY

PARENT

HOME

Mortgage or Rent

Maintenance

Lawn Care

2nd Mortgage

UTILITIES

Electric

Gas

Oil

Telephone

Cell Phone

Water

Sewer

Cable TV

Internet

Trash/Recycling

TAXES

Real Estate

Personal Property

INSURANCE

Homeowners/ Renters

Automobile

Life

Accident/ Disability

Excess Coverage

Long-Term Care

AUTOMOBILE

Lease or Loan Payments

Fuel

Repairs

Memberships

MEDICAL

Medical Insurance

Doctor

Dentist

Hospital

Medication

Counseling/ Therapy

Orthodontist

Special Needs (glasses, etc.)

EDUCATION

Tuition

Tutoring

Lessons

Other

PERSONAL

Debt Service

Clothing

Groceries

Haircare

Memberships

MISCELLANEOUS

Child Care

Household Help

Summer Camp

Papers/Books/Magazines

Entertainment

Pet Expenses

Vacations

Gifts

Legal Fees/Prof. Fees

Charitable Contributions

Children's Parties

Children's Allowances

Other Child Support

Alimony Payments

TOTAL MONTHLY EXPENSES

(d) The form used to obtain information relating to health insurance coverage from a party shall be in substantially the following form:

(Caption)

HEALTH INSURANCE COVERAGE INFORMATION REQUIRED BY THE COURT

This form must be completed and returned to the domestic relations section. IF YOU FAIL TO PROVIDE THE

INFORMATION REQUESTED, THE COURT MAY FIND THAT YOU ARE IN CONTEMPT OF COURT.

Do you provide insurance coverage for the dependents named below? (Check each type of insurance which you provide).

Type of Coverage

Full Name SS# Hospital- Medical Dental Eye Prescrip- Other
ization tion

______________________________ [ ] [ ] [ ] [ ] [ ] [ ]

Note: Before forwarding the form to the party, the domestic relations section should fill in the names and Social Security numbers of the dependents about whom the information is sought.

Provide the following information for all types of insurance you maintain, whether or not any of the above-named dependents is covered at this time:

Insurance company (provider):

Group #: _____ Plan #: _____ Policy #:

Effective coverage date: _____ Type of coverage:

Employee cost of coverage for dependents:

Insurance company (provider):

Group #: _____ Plan #: _____ Policy #:

Effective coverage date: _____ Type of coverage:

Employee cost of coverage for dependents:

Insurance company (provider):

Group #: _____ Plan #: _____ Policy #:

Effective coverage date: _____ Type of coverage:

Employee cost of coverage for dependents:

Insurance company (provider):

Group #: _____ Plan #: _____ Policy #:

Effective coverage date: _____ Type of coverage:

Employee cost of coverage for dependents:

If the above-named dependents are not currently covered by insurance, please state the earliest date coverage could be provided.

(e) The form of a support order shall be substantially as follows:

(Caption)

(FINAL) (TEMPORARY) (MODIFIED)

ORDER OF COURT

AND NOW, ______________________________, based upon the Court's determination that Payee's monthly net income is $____, and Payor's monthly net income is $__________, it is hereby ordered that the Payor pay to the Domestic Relations Section, Court of Common Pleas, __________ Dollars ($______.____) a month payable (WEEKLY/BI-WEEKLY/SEMI-MONTHLY/ MONTHLY) as follows:

. Arrears set at $__________ as of __________ are due in full IMMEDIATELY. Contempt proceedings, credit bureau reporting and tax refund offset certification will not be initiated, and judgment will not be entered, as long as payor pays $__________ on arrears on each payment date. Failure to make each payment on time and in full will cause all arrears to become subject to immediate collection by all of the means listed above.

For the support of: ______________________________________________________

______________________________________________________

Said money to be turned over by the domestic relations section to: ___________

Payments must be made (STATE ACCEPTABLE FORMS OF PAYMENT). All checks and money orders must be made payable to (NAME OF ENTITY TO WHOM CHECKS SHOULD BE MADE PAYABLE) and mailed to (NAME OF OFFICE) at (MAILING ADDRESS). Each payment must bear your (FILE/CASE/FOLIO/DOMESTIC RELATIONS) number in order to be processed. Do not send cash by mail.

Unreimbursed medical expenses are to be paid __________% by defendant and __________% by plaintiff. (PLAINTIFF/DEFENDANT/NEITHER) to provide medical insurance coverage. Within 30 days after the entry of this order, the party ordered to provide medical insurance shall submit to the other party written proof that medical insurance coverage has been obtained or that application for coverage has been made. Proof of coverage shall consist, at a minimum, of: 1) the name of the health care coverage provider(s); 2) any applicable identification numbers; 3) any
cards evidencing coverage; 4) the address to which claims should be made; 5) a description of any restrictions on usage, such as prior approval for hospital admissions, and the manner of obtaining approval; 6) a copy of the benefit booklet or coverage contract; 7) a description of all deductibles and co-payments; and 8) five copies of any claim forms.

IMPORTANT LEGAL NOTICE

PARTIES MUST WITHIN SEVEN DAYS INFORM THE DOMESTIC RELATIONS SECTION AND THE OTHER PARTIES, IN WRITING, OF ANY MATERIAL CHANGE IN CIRCUMSTANCES RELEVANT TO THE LEVEL OF SUPPORT OR THE ADMINISTRATION OF THE SUPPORT ORDER, INCLUDING, BUT NOT LIMITED TO, LOSS OR CHANGE OF INCOME OR EMPLOYMENT AND CHANGE OF PERSONAL ADDRESS OR CHANGE OF ADDRESS OF ANY CHILD RECEIVING SUPPORT. A PARTY WHO WILLFULLY FAILS TO REPORT A MATERIAL CHANGE IN CIRCUMSTANCE MAY BE ADJUDGED IN CONTEMPT OF COURT, AND MAY BE FINED OR IMPRISONED.

PENNSYLVANIA LAW PROVIDES THAT ALL SUPPORT ORDERS SHALL BE REVIEWED AT LEAST ONCE EVERY THREE (3) YEARS IF SUCH A REVIEW IS REQUESTED BY ONE OF THE PARTIES. IF YOU WISH TO REQUEST A REVIEW AND ADJUSTMENT OF YOUR ORDER, YOU MUST DO THE FOLLOWING: AN UNREPRESENTED PERSON WHO WANTS TO MODIFY (ADJUST) A SUPPORT ORDER SHOULD (insert instructions for local domestic relations section).

ALL CHARGING ORDERS FOR SPOUSAL SUPPORT AND ALIMONY PENDENTE LITE, INCLUDING UNALLOCATED ORDERS FOR CHILD AND SPOUSAL SUPPORT OR CHILD SUPPORT AND ALIMONY PENDENTE LITE, SHALL TERMINATE UPON THE DEATH OF THE PAYEE.

A MANDATORY INCOME ATTACHMENT WILL ISSUE UNLESS THE DEFENDANT IS NOT IN ARREARS IN PAYMENT IN AN AMOUNT EQUAL TO OR GREATER THAN ONE MONTH'S SUPPORT OBLIGATION AND (1) THE COURT FINDS THAT THERE IS GOOD CAUSE NOT TO REQUIRE IMMEDIATE INCOME WITHHOLDING; OR (2) A WRITTEN
AGREEMENT IS REACHED BETWEEN THE PARTIES WHICH PROVIDES FOR AN ALTERNATE ARRANGEMENT.

DELINQUENT ARREARAGE BALANCES MAY BE REPORTED TO CREDIT AGENCIES. ON AND AFTER THE DATE IT IS DUE, EACH UNPAID SUPPORT PAYMENT SHALL CONSTITUTE A JUDGMENT AGAINST YOU.

IT IS FURTHER ORDERED that, upon payor's failure to comply with this order, payor may be arrested and brought before the Court for a Contempt hearing; payor's wages, salary, commissions, and/or income may be attached in accordance with law; this Order will be increased without further hearing to $__________ a month until all arrearages are paid in full. Payor is responsible for court costs and fees.

Copies delivered to parties __________ (INDICATE DATE DELIVERED).

Consented: ______________________________________ ______________________________________

Plaintiff Plaintiff's Attorney

______________________________________ ______________________________________

Defendant Defendant's Attorney

BY THE COURT:

______________________________________

(f) A petition for modification of support shall be in substantially the following form:

(Caption)

PETITION FOR MODIFICATION

OF AN EXISTING SUPPORT ORDER

1. The petition of ____________________ respectfully represents that on ____________________, 19__________, an Order of Court was entered for the support of A true and correct copy of the order is attached to this petition.

2. Petitioner is entitled to __________ * of this Order because of the following material and substantial change(s) in circumstance:

* Fill in the relief sought, i.e. increase, decrease, modification, termination, suspension, vacation

WHEREFORE, Petitioner requests that the Court modify the existing order for support.

______________________________________

(Attorney for Petitioner) (Petitioner)

I verify that the statements made in this complaint are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities.

______________________________________ ______________________________________

Date Petitioner

(g) The order to be attached at the front of the petition for modification set forth in subdivision (f) shall be in substantially the following form:

(Caption)

ORDER OF COURT

You, __________, Respondent, have been sued in Court to modify an existing support order. You are ordered to appear in person at __________ on __________ at _____________.M., for a conference/hearing and to remain until dismissed by the Court. If you fail to appear as provided in this Order, an Order for Modification may be entered against you.

You are further ordered to bring to the conference

(1) a true copy of your most recent Federal Income Tax Return, including W-2s, as filed,

(2) your pay stubs for the preceding six months,

(3) the Income and Expense Statement attached to this order, completed as required by Rule 1910.11(c),

(4) verification of child care expenses, and

(5) proof of medical coverage which you may have, or may have available to you.

THE APPROPRIATE COURT OFFICER MAY MODIFY OR TERMINATE THE EXISTING ORDER IN ANY MANNER BASED UPON THE EVIDENCE PRESENTED.

Date of Order: ______________________________________ ______________________________________

YOU HAVE THE RIGHT TO A LAWYER, WHO MAY ATTEND THE CONFERENCE AND REPRESENT YOU. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE
MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE.

_____________________________

(Name)

_____________________________

(Address)

_____________________________

(Telephone Number)

AMERICANS WITH DISABILITIES ACT OF 1990

The Court of Common Pleas of __________ County is required by law to comply with the Americans with Disabilities Act of 1990. For information about accessible facilities and reasonable accommodations available to disabled individuals having business before the court, please contact our office. All arrangements must be made at least 72 hours prior to any hearing or business before the court. You must attend the scheduled conference or hearing.