SRMT CSEU Case No.________________________
SRMT Tribal Court Docket No.________________________
Page 2 of 3
Child’s Name: _____________________________________
Child’s Date of Birth: _______________________________
Child’s Tribal Affiliation: ____________________________
Paternity was established on , through:
□ A signed birth certificate which is attached hereto.
□ An acknowledgement executed by the parties
□ By a judgment rendered by a court of competent jurisdiction and which is attached hereto
Currently, this child resides at , which □ IS / □ IS NOT
the same residence as the petitioner. (FSA Sec III 2B (vii)
Based on the facts stated under oath herein, this court has jurisdiction over this petition and the respondent
because [CHECK ALL THAT APPLY]:
□ I am, □ my child is, or □ my children listed below are enrolled members of the Saint Regis Mohawk Tribe.
□ I reside or am domiciled, □ my child resides or is domiciled, or □ my children listed below reside or are
domiciled within the territory of the Saint Regis Mohawk Tribe.
□ The respondent is an enrolled member of the Saint Regis Mohawk Tribe.
□ The respondent resides or is domiciled within the territory of the Saint Regis Mohawk Tribe.
□ The respondent has had minimum contacts with the Tribe and its territory and is subject to this court’s
personal jurisdiction based on the facts alleged in this petition.
2) The biological Mother is:
3) The putative/biological Father is:
4) The attached order of support was issued by the State of ____________________(court) on
_______________, a court of competent jurisdiction to exercise authority over the child support request as
found by that court in the attached order.