JV-023 (Rev. 06/10/2013) [Case Type: TS (Temporary Support)]
COMPLAINT FOR A TEMPORARY
ORDER OF SUPPORT
G.L. c. 119, § 28
DOCKET NUMBER
Trial Court of Massachusetts
Juvenile Court Department
1. Plaintiff, , who resides at
is
(print or type full name)
Signature of Attorney, or Plaintiff, if pro se
Address
This matter shall be heard in conjunction with the petition filed pursuant to G. L. c. 119, § 24.
Date:
(street and no.) (city or town) (county) (state) (zip code)
child
mother
father
guardian/custodian
parent/personal representative of the mother/father of the child
the Department of Children and Families/agency licensed under G. L. c. 28A
the Department of Transitional Assistance/Department of Revenue
2. The child for whom support is sought:
(social security number)(date of birth)(name)
(zip code)(state)(county)(city or town)(street and no.)
3. Defendant(s) is/are:
Name:
Address:
DOB:
SSN:
Relationship to child:
4. Are the child's mother and father currently married to each other? Yes No
If no, are mother and father divorced or separated? Yes No
5. If the answers to Question No. 4 are no, has paternity been adjudicated? Yes No
If yes, date paternity was adjudicated Court
6. Who has custody of the child?
7. A copy of the child's birth certificate is attached.
WHEREFORE, the plaintiff requests that the Court:
order a suitable amount of support for said child.
order the defendant to maintain/provide health insurance for the benefit of the child.
DIVISION
Telephone No.
BBO No.
