Form Sca Fc 201 – Fill Out and Use This PDF

IN THE FAMILY COURT OF ________________ COUNTY, WEST VIRGINIA.

In Re:
The Marriage / Children of:		Civil Action No. ____________
_________________________,	and	_________________________.
Petitioner		Respondent
_________________________		_________________________
_________________________		_________________________
Address		Address
________________		________________
Daytime phone		Daytime phone

PETITION FOR MODIFICATION

1.General Information

a. The Petitioner is: ________________________, who is:

(Print your name.)

___ the mother / wife whose name is listed in the case style at the top of this page.

___ the father / husband whose name is listed in the case style at the top of this page.

___ other person, whose relationship to the Respondent / children is: __________________

______________________________________________________________________.

b.The Petitioner requests that the Order entered on the date of ________________________ be modified with regard to:

___ Parenting Plan

___ Child support

___ Spousal support

___ Other; (Explain) _________________________________________________________

__________________________________________________________________.

=

2.I want the Court to modify the Order in these ways: (Check all that apply.)

___	Increase child support
___	Decrease child support	___ End child support
___	Change Parenting Plan with regard to: ___ Decision making;

___ Time spent with the children; ___ Other; (Explain) ________________________

__________________________________________________________________.

___ Order child support paid to another person, who

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Petition for Modification

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is:_____________________________.
___	Order child support paid by another person, who
is:_____________________________.
___	Increase spousal support
___	Decrease spousal support	___ End spousal support

___ Other modification request(s); (Explain.) _______________________________________

_______________________________________________________________________

______________________________________________________________________.

=

3.Circumstances that justify the modification I am requesting.

(Explain all of the changes in circumstances you think justify the modifications you requested.) :

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________.

4.Information concerning Public Assistance and Child Support Enforcement Services

a.___ A Public Assistance check from Health and Human Services is now being received by: ___ The Children; ___ The Petitioner; ___ The Respondent.

b.___ A Public Assistance check from Health and Human Services was received in the past by: ___ The Children; ___ The Petitioner; ___ The Respondent.

c.___ Services from the Bureau for Child Support Enforcement have been applied for by:

___ The Petitioner; ___ The Respondent.

d.___ Income withholding services are currently being received from the Bureau for Child Support Enforcement.

_________________________________	___________________
Petitioner’s Signature	Date

You must sign the Verification on the next page before a Notary Public.

VERIFICATION

I, ____________________________, after making an oath or affirmation to tell the truth, say

that the facts I have stated in this Petition are true of my personal knowledge; and if I have set

forth matters upon information given to me by others, I believe that information to be true.

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Petition for Modification

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___________________________	___________________
Signature	Date

This Verification was sworn to or affirmed before me on the ____ day of __________________,

2_____.

_________________________

Notary Public / Other official

My commission expires:______________________.

CERTIFICATE OF SERVICE

State of West Virginia

County of _______________________________

I, ____________________________, the Petitioner for Modification, mailed my Petition

by first class United States Mail, postage paid, to:

______________________________________________________________________________

(Name and Address)

________________________________

(Date mailed)

And:

______________________________________________________________________________

(Name and Address)

________________________________

(Date mailed)

___________________________	____________
Petitioner’s Signature	Date

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Petition for Modification

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