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APPEARANCE BY UNREPRESENTED PERSON IN CIVIL CASE (Indiana)

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Page 1 of 3 Approved by the Coalition for Court Access
CCA-DC-0519-3013
STATE OF INDIANA ) IN THE ___________________ _____________ COURT
)SS:
COUNTY OF _________________ ) CASE NO. __________________________________
IN RE THE ____________________ OF:
_______________________________
Minor Child (paternity only)
_______________________________
Petitioner,
v.
_______________________________
Respondent
APPEARANCE BY UNREPRESENTED PERSON IN CIVIL CASE
This Appearance Form must be filed on behalf of every party in a civil case.
1. My name is _________________________________ and I am:
☐ Initiating (filing)
☐ Responding (answering or defending)
☐ Intervening
in this case I am not represented by a lawyer.
2. Contact information for receiving legal service of document and case information as required by Court
Rules. (NOTE: If you are the Initiating Party and this case, or a related case, involves a protection
from abuse order, a workplace violence restraining order, or a no-contact order, you must provide an
address for the purpose of legal service of documents. But, that address should not be one that exposes
your location.)
Address:
Email address:
☐ I will accept service at the above email address.
Phone:
Fax:
--------------------------------------------------------------------------------------------------------------------------------------
INSTRUCTIONS: MODIFY CHILD SUPPORT WITHOUT AGREEMENT
FOR THE SECTION ABOVE THE DOTTED YELLOW LINE
LOOK AT THE COURT PAPERS YOU HAVE IN THIS CASE
AND COPY THE INFORMATION HERE
YOUR NAME HERE
IF YOUR NAME IS ABOVE 'PETITIONER',
CHECK 'INITIATING' IF YOUR NAME IS
ABOVE RESPONDENT, CHECK
'RESPONDING'
YOUR ADDRESS
YOUR EMAIL
IF YOU HAVE AN EMAIL THAT YOU CHECK
EVERY DAY AND ONLY WANT THE COURT TO
SEND YOU INFORMATION VIA EMAIL, CHECK
THIS BOX
YOUR PHONE NUMBER
YOUR FAX NUMBER (IF YOU HAVE ONE)
PRINT FORMS
CLEAR FORMS
__________________
_________________
Page 2 of 3 Approved by the Coalition for Court Access
CCA-DC-0519-3013
OR, if in a related case, you have used the Attorney General confidential address, you may check the
box below:
☐ Attorney General confidential address
3. This is a _____ case type as defined in Administrative Rule 8(B)(3).
(The Clerk will tell you the case type if you do not know it, so you may handwrite your response at the
Clerk’s Office.)
4. This case involves child support issues and the names and social security numbers of all family
members are on a separately attached document marked “Not For Public Access In Accordance With
Administrative Rule 9)
5. There are related cases: (If yes, please indicate below)
☐ Yes
☐ No
Caption and case number of related cases:
Caption: Case No.:
Caption: Case No.:
Caption: Case No.:
Additional information as required by local rule:
Signature
CERTIFICATE OF SERVICE
I hereby certify that I sent a copy of this Appearance by first class mail to the opposing party’s attorney,
or to the opposing party if the opposing party is not represented by an attorney on
______________________________.
Signature
IF YOU USE
THE ATTORNEY
GENERAL
CONFIDENTIAL
ADDRESS,
CHECK THIS
BOX
IF THERE ARE OTHER CASES RELATED TO THIS ONE, CHECK YES
AND FILL OUT THE BLANKS BELOW
IF ADDITIONAL INFORMATION IS REQUIRED BY LOCAL COURT RULE, ADD IT HERE
Page 1 of 1 Approved by the Coalition for Court Access
CCA-DC-0320-1069
www.indianalegalhelp.org
NOT FOR PUBLIC ACCESS
IN ACCORDANCE WITH INDIANA RULES ON
ACCESS TO COURT RECORDS
ATTEN
TION CLERK: FOR SELF REPRESENTED LITIGANTS TREAT THIS FORM AS IF IT
IS PRINTED ON LIGHT GREEN PAPER. IF E-FILED, FILE AS A CONFIDENTIAL
DOCUMENT.
STATE OF INDIANA IN THE ____________________ ___________ COURT
COUNTY OF __________________ CAUSE NO: _____________________________
IN THE ________________OF
_______________________
Minor Child (paternity only)
_______________________
Petitioner
vs.
_______________________
Respondent
CIVIL APPEARANCE FORM
Social security numbers of all family members in cases involving child support
Name: ______________________________________SS#________________________________
Name: ______________________________________SS#________________________________
Name: ______________________________________SS#________________________________
Name: ______________________________________SS#________________________________
Name: ______________________________________SS#________________________________
Name: ______________________________________SS#________________________________
NOT FOR PUBLIC ACCESS
-----------------------------------------------------------------------------------------------------------------------------------------
FOR THE SECTION ABOVE THE DOTTED LINE, LOOK AT
THE COURT PAPERS YOU HAVE IN YOUR CASE AND COPY
THE INFORMATION HERE.
YOUR NAME YOUR SOCIAL SECURITY NUMBER
CHILD'S NAME CHILD'S SOCIAL SECURITY NUMBER
OTHER PARENT'S NAME OTHER PARENT'S SOCIAL SECURITY NUMBER
Page 1 of 2 Approved by the Coalition for Court Access
CCA-DC-0519-1004
STATE OF INDIANA ) IN THE ______________ _______________ COURT
)SS:
COUNTY OF __________________ ) CASE NO. ___________________________________
IN RE THE _________________ OF:
_______________________________
Minor Child (paternity only)
_______________________________
Petitioner,
v.
_______________________________
Respondent.
Comes now _______________________, self represented, and hereby files a Verified Petition
For Modification of Child Support, and states as follows:
1. That parties have ______ minor child(ren), namely:
Name Date of birth
2. ____________________________________ is ordered to pay $______________ in
current child support effective on __________________.
3. Since that time, there has been a change in circumstances that makes the current order vary
more than 20% from what the child support guidelines would indicate should be paid, or so substantial
and continuing as to make the terms of the current support order unreasonable for the following reasons:
------------------------------------------------------------------------------------------------------------------------------------
VERIFIED PETITION FOR MODIFICATION OF CHILD SUPPORT
FOR THE SECTION ABOVE THE DOTTED LINE
LOOK AT THE OTHER PAPERS YOU HAVE IN THIS
CASE AND COPY THE INFORMATION HERE
YOUR FULL NAME
NUMBER OF CHILDREN YOU
HAVE WITH THE OTHER PARENT
NAMES AND DATES OF BIRTH OF EACH CHILD YOU HAVE WITH THE OTHER
PARENT
PERSON ORDERED TO PAY CHILD SUPPORT
AMOUNT ORDERED
TO BE PAID
DATE CURRENT CHILD SUPPORT TOOK EFFECT
__________________
_________________
Page 2 of 2 Approved by the Coalition for Court Access
CCA-DC-0519-1004
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
4. Child support should be modified to reflect the
substantial change in circumstances
outlined above.
5. Arrearages are not determined at this time and are reserved for a later date.
6. ___________________________________ requests the Court address the tax exemption
assignment.
7. A hea
ring should be set to determine if child support should be changed.
WHEREFORE,_____________________________ requests that this Court set this matter for
hearing, and upon hearing, modify the existing child support as is appropriate, and order all other further
relief that is just and proper in the premises.
I affirm under the penalties of perjury that the foregoing representations are true.
____________________________________ ____________________________________
Signature Date
____________________________________
Printed Name
CERTIFICATE OF SERVICE
I hereby certify that I sent a copy of tis Petition by first class mail to the opposing attorney, or the
opposing party if the opposing party is not represented by an attorney, on ______________________.
____________________________________
Signature
as
DESCRIBE THE CHANGE IN CIRCUMSTANCES THAT CAUSED YOU TO ASK FOR A
CHILD SUPPORT MODIFICATION
YOUR NAME
YOUR NAME
PRINT THIS FORM AND THEN SIGN AND DATE IT HERE
YOUR NAME
DATE SENT TO OTHER PARTY
PRINT THIS FORM AND THEN SIGN
IT HERE
Page 1 of 1 Approved by the Coalition for Court Access
CCA-DC-0519-1005
STATE OF INDIANA ) IN THE ______________ _______________ COURT
)SS:
COUNTY OF __________________ ) CASE NO. ___________________________________
IN RE THE _________________ OF:
_______________________________
Minor Child (paternity only)
_______________________________
Petitioner,
v.
_______________________________
Respondent.
ORDER SETTING HEARING
Comes now _____________________________________, pro se, having filed a Verified
Petition For Modification Of Child Support, and the Court finds that the matter should be set for hearing.
IT IS THEREFORE ORDERED that this matter shall be heard on
__________________________________________________________________________________.
____________________________________ _____________________________________
Date Judicial Officer
☐ The Clerk shall serve this pleading upon __________________________________ by
certified mail at the following address (this requires an additional fee payable to the Clerk):
____________________________________________
____________________________________________
____________________________________________
☐ The Clerk shall have this pleading served upon _____________________________ by
sheriff at the following address:
____________________________________________
____________________________________________
____________________________________________
Distribution:
___________________________________________
___________________________________________
-----------------------------------------------------------------------------------------------------------------------------------
FOR THE SECTION ABOVE THE DOTTED LINE
LOOK AT THE OTHER COURT PAPERS YOU HAVE
IN THIS CASE AND COPY THE INFORMATION
HERE
FULL NAME
LEAVE BLANK
LEAVE BLANK
LEAVE BLANK
PETITIONER'S NAME
RESPONDENT'S NAME
CHOOSE HOW YOU WANT THE
OTHER PARTY TO RECEIVE
THESE DOCUMENTS: EITHER
BY CERTIFIED MAIL OR BY
SHERIFF. THERE MAY BE
COSTS ASSOCIATED WITH
EACH TYPE OF SERVICE.
FILL IN THE OTHER PARTY'S
NAME AND ADDRESS AFTER
YOU CHOOSE HOW THE OTHER
PERSON WILL BE SERVED.
__________________
Page 1 of 3 Approved by the Coalition for Court Access
CCA-DC-0519-1033
STATE OF INDIANA ) IN THE ___________________ _____________ COURT
)SS:
COUNTY OF _________________ ) CASE NO. __________________________________
IN RE THE ____________________ OF:
_______________________________
Minor Child (paternity only)
_______________________________
Petitioner,
v.
_______________________________
Respondent
ORDER FOR MODIFICATION OF CHILD SUPPORT
Comes now, ________________________, self represented, having filed a Verified Petition For
Modification Of Child Support and the Court having been duly advised in the premises, now finds that there
has been a change in circumstances so substantial and continuing as to make the terms of the current child
support order unreasonable, and that the child support order should be modified to reflect the substantial
change in circumstances.
IT IS THEREFORE ORDERED that:
1. ____________________________________ is to pay child support in the amount of
$___________________ per week, effective on _________________________.
3. All support payments shall be made through the County Clerk’s Office (cash payments only)
or the State Central Collection Unit Po box 7130, Indianapolis, Indiana 46207-7130 (any payments other
than cash). The court shall issue and immediately activate an Income Withholding Order pursuant to IC §
31-16-15 to any employer or income provider to the child support Obligor.
4. Arrearages are not determined at this time and are reserved for a later date.
5.
☐_____________________________ shall maintain medical, dental and optical insurance
as available through employment, or Health Insurance Marketplace, or by government provided insurance
---------------------------------------------------------------------------------------------------------------------------------------
FOR THE SECTION ABOVE THE DOTTED LINE LOOK AT
THE OTHER COURT PAPERS YOU HAVE IN THIS CASE
AND COPY THE INFORMATION HERE
FULL NAME
LEAVE THIS
SECTION BLANK
__________________
_________________
Page 2 of 3 Approved by the Coalition for Court Access
CCA-DC-0519-1033
for the minor child(ren).
-OR-
☐ Health insurance for the child(ren) is not available to either parent at a reasonable
cost, therefore neither party is ordered to provide health insurance at this time. In the event that health
insurance for the child(ren) becomes available at a reasonably cost to one or both of the parties, the party to
whom such coverage is available shall obtain coverage for the children within a reasonable time after such
coverage becomes available.
6.
☐_____________________________ shall be entitled to claim the minor child(ren) for
federal, state, and local income tax purposes on an annual basis. The parties shall cooperate to sign all
necessary documents that will allow the party claiming the exemption to do so.
The non-custodial parent’s right to this exemption is conditioned on them being 95% compliant in
their support by January 31 of their tax year pursuant to IC § 31-16-6-1.5(d). The custodial parent shall take
all actions necessary to release their claim to the exemption in the manner required under Section 152(e) of
the Internal Revenue Code.
-OR-
☐Petitioner and Respondent shall each be entitled to claim the minor child(ren) for federal,
state and local income tax purposes in alternating years. Petitioner shall be entitled to claim the minor
child(ren) in the year __________, and every ______ year thereafter. Respondent shall be entitled to claim
the minor child(ren) in the year ________ and every ________ year thereafter. The parties shall cooperate
to sign all necessary documents that will allow the party claiming the exemption to do so.
The non-custodial parent’s right to this exemption is conditioned on them being 95% compliant in
their support by January 31 of their tax year pursuant to I § 31-16-6-1.5(d). The custodial parent shall take
all actions necessary to release their claim to the exemption in the manner required under Section 152(e) of
the Internal Revenue Code.
7. ________________________________ will be responsible for the first $_______________
per year of uninsured health and medical, dental, optical, hospital and prescription expenses for the minor
child(ren). Thereafter, Petitioner shall be responsible for ____% of annual uninsured health and medical,
dental, optical hospital and prescription expenses for minor child(ren), and Respondent shall be responsible
LEAVE THIS
PAGE BLANK
Page 3 of 3 Approved by the Coalition for Court Access
CCA-DC-0519-1033
for ____% of annual uninsured health and medical, dental, optical hospital and prescription expenses for
minor c
hild(ren).
So ordered _________________________________________________________________________
____________________________________
Judicial Officer
Distribution:
________________________________________
________________________________________
PETITIONER
RESPONDENT
LEAVE BLANK
LEAVE BLANK
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APPEARANCE BY UNREPRESENTED PERSON IN CIVIL CASE (Indiana)

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Completed 18 August 2020

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