Free CV-041, Statement Concerning Public Assistance, Rev. 10/01 - Maine


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State: Maine
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STATE OF MAINE SUPERIOR COURT , ss. Docket No. DISTRICT COURT Location Docket No. ______ ______

Plaintiff v. Defendant STATEMENT CONCERNING PUBLIC ASSISTANCE

I make the following statements. (Check one statement in each section that applies.) 1. The child(ren) of the parties in this action A. Have never received TANF or Medicaid. Neither party intends to file an application for TANFor Medicaid for the child(ren). B. Have received or are now receiving TANF or Medicaid. C. A party intends to file an application for TANF or Medicaid for the child(ren). If B or C is checked, you must send a copy of the complaint or motion to the Department of Human Services, Support Enforcement Division, Central Office Supervisor, State House Station 11, Augusta, ME 04333-0011. 2. Of the parties in this action A. (Plaintiff) (Defendant) is a support enforcement client of the Department of Human Services or has requested the assistance of the Department in establishing, reviewing, modifying, or enforcing a child support order concerning the child(ren). B. Neither party has contacted the Department of Human Services for the establishment, review, modification, or enforcement of a child support order concerning the child(ren). 3. The Department of Human Services A. Has not issued a child support order concerning the child(ren). B. Has issued a child support order concerning the child(ren). If B is checked, you must attach a copy of the order.

Date: Signature of (Plaintiff) (Defendant)
CV-041, Rev. 10/01