Forms for Establishing and Modifying Support Orders - Tennessee - Edit, Fill, Sign Online

June, 2009 (Revised) 1

RULES

OF

TENNESSEE DEPARTMENT OF HUMAN SERVICES

CHILD SUPPORT SERVICES DIVISION

CHAPTER 1240-02-01

FORMS FOR ESTABLISHING AND MODIFYING SUPPORT ORDERS

TABLE OF CONTENTS

1240-02-01-.01 Petition Forms 1240-02-01-.03 Notice of Hearing Form

1240-02-01-.02 Affidavit Form

1240-02-01-.01 PETITION FORMS.

(1) The following form, or another form containing all of the information herein, may be used to

commence an action to establish a support order pursuant to T.C.A. § 36-5-401 et seq.

IN THE _____________ COURT OF ______________ COUNTY, TENNESSEE

STATE OF TENNESSEE ex. rel.,

_____________________________________

Petitioner

Docket No. ________________

v.

IV-D No. ________________

_____________________________________

Respondent

PETITION TO SET SUPPORT

Comes the Petitioner, and would respectfully request this Honorable Court to issue an order of support

for the minor children:

__________________________, DOB _________________

Petitioner alleges he/she is the:

(check one) ____ mother

____ father

____ non-parent caretaker

of the above-named child(ren) who are in his/her physical custody. Petitioner alleges the child(ren) have

been in his/her physical custody since:

(check one) ____ birth

____ date of physical custody ___________________________________

Petitioner alleges there is no other person or entity entitled to support for these child(ren) for the time

petitioner has had physical custody.

Petitioner alleges Respondent(s) is/are the legal parent(s) of the child(ren) and have a duty to support the

child(ren).

WHEREFORE, PETITIONER PRAYS:

1. That this petition be filed and proper process issue.

2. That this Court set current and retroactive child support for said child(ren) in accordance with

the State guidelines, including medical support for said child(ren), to be paid by income

assignment to Central Collections.

3. That the Respondent be ordered to pay the costs of this cause.

FORMS FOR ESTABLISHING AND MODIFYING SUPPORT ORDERS CHAPTER 1240-02-01

(Rule 1240-02-01-.01, continued)

June, 2009 (Revised)

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4. For such other and further relief as this cause may require.

_______________________________

Petitioner

_______________________________

Petitioner’s Address and Phone

_______________________________

STATE OF TENNESSEE

COUNTY OF ____________________

_____________________________________, petitioner, being first duly sworn, affirms that the

petitioner has read the foregoing petition, knows the contents of the petition, and that the petition is true

and correct to the best of petitioner’s knowledge, information and belief.

_____________________________

Petitioner

Sworn to and subscribed before me this ____ day of ___________________, 20___.

_______________________________

NOTARY PUBLIC / CLERK

My commission expires: _________________

(2) The following form, or another form containing all of the information herein, may be used to

commence an action to modify a support order pursuant to T.C.A. § 36-5-401 et seq. Where

the petition language indicates a choice between Petitioner or Respondent, circle the

appropriate choice.

IN THE _____________ COURT OF ______________ COUNTY, TENNESSEE

STATE OF TENNESSEE ex. rel.,

_____________________________________

Petitioner

Docket No. ________________

v.

IV-D No. ________________

_____________________________________

Respondent

PETITION FOR MODIFICATION

Comes the Petitioner / Respondent, and would respectfully show this Honorable Court that an order was

entered herein whereby the Respondent was ordered to pay support for the minor children:

__________________________, DOB _________________

in the amount of $_________ monthly. Petitioner / Respondent alleges that it is appropriate to modify

child support for the following reason(s):

_____________________________________________________________________________

____________________________________________________________________________ ,

FORMS FOR ESTABLISHING AND MODIFYING SUPPORT ORDERS CHAPTER 1240-02-01

(Rule 1240-02-01-.01, continued)

June, 2009 (Revised)

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which results in a significant variance according to the child support guidelines.

WHEREFORE, PETITIONER / RESPONDENT PRAYS:

1. That this petition be filed and proper process issue.

2. That this Court modify the child support for said children in accordance with the State

guidelines, including medical support, with support to be paid by income assignment to the

state Central Collections unit for said children.

3. That the Petitioner / Respondent be ordered to pay the costs of this cause.

4. For such other and further relief as this cause may require.

_____________________________________

Petitioner / Respondent

_____________________________________

Petitioner’s / Respondent’s Address and Phone

_____________________________________

STATE OF TENNESSEE

COUNTY OF ____________________

_____________________________________, being first duly sworn, affirms that he/she has read the

foregoing petition, knows the contents of the petition, and that the petition is true and correct to the best

of his/her knowledge, information and belief.

____________________________________

Petitioner / Respondent

Sworn to and subscribed before me this ____ day of ___________________, 20___.

____________________________________

NOTARY PUBLIC / CLERK

My commission expires: _________________

(3) The following form, or another form containing all of the information herein, may be used to

commence an action to enforce a support order pursuant to T.C.A. § 36-5-401 et seq.

IN THE _____________ COURT OF ______________ COUNTY, TENNESSEE

STATE OF TENNESSEE ex. rel.,

_____________________________________

Petitioner

Docket No. ________________

v.

IV-D No. ________________

_____________________________________

Respondent

PETITION TO ENFORCE CHILD SUPPORT

Comes the Petitioner, and would respectfully show this Honorable Court that an order was entered herein

whereby the Respondent was ordered to pay support for the minor child(ren):

__________________________, DOB _________________

FORMS FOR ESTABLISHING AND MODIFYING SUPPORT ORDERS CHAPTER 1240-02-01

(Rule 1240-02-01-.01, continued)

June, 2009 (Revised)

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__________________________, DOB _________________

in the amount of $________ monthly. Petitioner alleges Respondent is not paying support according to

the terms of the order.

WHEREFORE, PETITIONER PRAYS:

1. That this petition be filed and proper process issue.

2. That this Court enforce the child support for said child(ren) by any means the court finds

appropriate, including but not limited to income assignment, issuance of liens on real and/or

personal property of respondent, requiring a bond or security to assure payment.

3. That the Respondent be ordered to pay the costs of this cause.

4. For such other and further relief as this cause may require.

_____________________________________

Petitioner

_____________________________________

Petitioner’s Address and Phone

_____________________________________

STATE OF TENNESSEE

COUNTY OF ____________________

_____________________________________, petitioner, being first duly sworn, affirms that the

petitioner has read the foregoing petition, knows the contents of the petition, and that the petition is true

and correct to the best of petitioner’s knowledge, information and belief.

____________________________________

Petitioner

Sworn to and subscribed before me this ____ day of ___________________, 20___.

____________________________________

NOTARY PUBLIC / CLERK

My commission expires: _________________

Authority: T.C.A. §36-5-406. Administrative History: New rule filed December 17, 1985; effective

January 14, 1986. Amendment filed March 24, 2009; effective June 7, 2009.

1240-02-01-.02 AFFIDAVIT FORM. The following form may be used with the Petition to Set Support

and Petition for Modification found in Rule 1240-02-01-.01(1) and (2). Where the petition language

indicates a choice between Petitioner or Respondent, circle the appropriate choice.

IN THE _____________ COURT OF ______________ COUNTY, TENNESSEE

STATE OF TENNESSEE ex. rel.,

_____________________________________

Petitioner

Docket No. ________________

v.

IV-D No. ________________

_____________________________________

Respondent

FORMS FOR ESTABLISHING AND MODIFYING SUPPORT ORDERS CHAPTER 1240-02-01

(Rule 1240-02-01-.02, continued)

June, 2009 (Revised)

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AFFIDAVIT

Comes the Petitioner / Respondent, and being first duly sworn, states (select all that apply and fill in the

blanks):

1. The child(ren) named in the petition reside with me:

_____ less than 50% of the time

_____ exactly 50% of the time

_____ more than 50% of the time

2.

_____ I am married to the petitioner / respondent, but we are living separately.

_____ I have never been married to the petitioner/ respondent.

_____ I am divorced from the petitioner / respondent by order of the _________ Court of _______

County, ______ (state), Docket number _______________, effective date ____________.

3. The child(ren) spend _______ (number) days per month/year with the respondent, with each day

being more than twelve (12) consecutive hours in a twenty-four (24) hour period.

4.

_____ There is not an order for the support of the child(ren).

_____ The most recent order for support of the child(ren) is from the _________ Court of

_________ County, ______ (state), Docket number _______________, effective date

______________, in the amount of $________ per month.

5. I pay for the child(ren)’s medical insurance, at a cost of $________ monthly.

6. I pay for the child(ren)’s dental insurance, at a cost of $________ monthly.

7. I pay for work-related child care for the child(ren) at a cost of $________ monthly.

8. The deductible or co- pay for the child(ren)’s medical care is $_________ per

_______________________ (visit, month, annual).

9. I pay $_____________ per month for the child(ren)’s recurring medical expenses.

10. The child(ren) participate in the following enriching and/or extracurricular activities at a cost of

$_________ monthly: ________________________________________________

________________________________________________________________________

11. The child(ren) incur the following educational expenses at an average monthly cost of

$___________ : ___________________________________________________________

________________________________________________________________________

12. My average gross monthly income from all non-exempt sources is $___________.

13. I am the legal parent of _____ (number) other qualified minor children who live in my home 50% of

the time or more.

14. I am the legal parent of _____ (number) of minor children who live in my home less than 50% of the

time. Over the last 12 months I have provided support for these children in the average amount of

$_________ monthly.

___________________________________

Petitioner / Respondent

Sworn to and subscribed before me this ____ day of ___________________, 20___.

____________________________________

NOTARY PUBLIC / CLERK

My commission expires: _________________

Authority: T.C.A. §36-5-406. Administrative History: New rule filed December 17, 1985; effective

January 14, 1986. Amendment filed March 24, 2009; effective June 7, 2009.

1240-02-01-.03 NOTICE OF HEARING FORM. The following form may be used to notify respondent

that a Petition to establish, modify or enforce support has been filed against him/her, pursuant to T.C.A.

§36-5-401 et seq., and to notify the respondent of the time, date and location of the hearing thereon:

FORMS FOR ESTABLISHING AND MODIFYING SUPPORT ORDERS CHAPTER 1240-02-01

(Rule 1240-02-01-.03, continued)

June, 2009 (Revised)

6

IN THE _____________ COURT OF ______________ COUNTY, TENNESSEE

STATE OF TENNESSEE ex. rel.,

_____________________________________

Petitioner

Docket No. ________________

v.

IV-D No. ________________

_____________________________________

Respondent

NOTICE OF HEARING

TO THE PETITIONER / RESPONDENT, ___________________________________________

Notice is hereby given to you, _____________________________ that the Petitioner / Respondent will

appear before the Honorable _____________________________, Referee / Judge of the ___________

Court for ______________ County, Tennessee, on the ____ day of ______________, 20___ at _______

o’clock ___.m. You may be represented by a lawyer if you chose. This hearing will be held at the

following place:

_____________________________________________________________________________

The Petitioner / Respondent will be requesting the Court: (check appropriate section)

_____ Order support for the child(ren) listed in the attached Petition to Set Support.

_____ Enforce the order of support as set out in the attached Petition to Enforce Support.

_____ Modify support as set out in the attached Petition to Modify Support.

IF YOU WANT TO TELL YOUR SIDE TO THE COURT, YOU MUST BE AT THE HEARING. BRING

PROOF OF YOUR GROSS MONTHLY INCOME TO THE HEARING. IF YOU DO NOT COME TO THE

HEARING, THE COURT WILL DECIDE BASED ONLY ON THE PETITIONER’S / RESPONDENT’S

TESTIMONY AND MAY ISSUE AN ORDER GRANTING THE RELIEF SOUGHT IN THE PETITION.

_____________________________________

CLERK

Certificate of Service

I certify that a copy of this Notice and Petition with any attachments was given to Petitioner / Respondent

and was served on Petitioner / Respondent by mailing, return receipt requested, on the ____ day of

__________ 20 ___.

___________________________________

CLERK

Authority: T.C.A. §36-5-406. Administrative History: New rule filed December 17, 1985; effective

January 14, 1986. Amendment filed March 24, 2009; effective June 7, 2009.

Fillable Printable Forms for Establishing and Modifying Support Orders - Tennessee

Fillable Printable Forms for Establishing and Modifying Support Orders - Tennessee

Forms for Establishing and Modifying Support Orders - Tennessee