Rule 1910.27. Form of Complaint. Order. Income Statements and Expense Statements. Health Insurance Coverage Information Form. Form of Support Order. Form Petition for Modification.

 (a)  The complaint in an action for support shall be substantially in the following form:

 (Caption)
COMPLAINT FOR SUPPORT

      1. Plaintiff resides at

     2. Defendant resides at

      3. (a) Plaintiff and Defendant were married on

        (b) Plaintiff and Defendant were separated on

        (c) Plaintiff and Defendant were divorced on

      4. Plaintiff and Defendant are the parents of the following children:

        (a) Born of the Marriage:
Name    Birth Date    Age    Residence

        (b) Born out of Wedlock:
Name    Birth Date    Age    Residence

      5. Plaintiff seeks support for the following persons:

      6. (a) Plaintiff is (not) receiving public assistance in the amount of $

         (b) Plaintiff is receiving additional income in the amount of $

      7. A previous support order was entered against the defendant on

      8. Plaintiff last received support from the Defendant in the amount of $

   WHEREFORE, Plaintiff requests that an order be entered against Defendant and in favor of the Plaintiff and the aforementioned child(ren) for reasonable support and medical coverage.

   I verify that the statements made in this Complaint and attached Income and Expense Statement are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. §  4904, relating to unsworn falsification to authorities.

NOTICE

 Guidelines for child and spousal support, and for alimony pendente lite have been prepared by the Court of Common Pleas and are available for inspection in the office of Domestic Relations Section,

 (b) The order to be attached at the front of the complaint set forth in subdivision (a) shall be in substantially the following form:

 (Caption)

 ORDER OF COURT

 You,

   YOU HAVE THE RIGHT TO A LAWYER, WHO MAY ATTEND THE CONFERENCE AND REPRESENT YOU. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER.

   IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE.

 AMERICANS WITH DISABILITIES ACT OF 1990

 The Court of Common Pleas of

 (c) The Income and Expense Statements to be attached to the order shall be in substantially the following form:

  (1) Income Statement. This form must be filled out in all cases.

 THIS FORM MUST BE FILLED OUT
(If you are self-employed or if you are salaried by a business of which you are owner in whole or in part, you must also fill out the Supplemental Income Statement which appears below.
INCOME STATEMENT OF
        (Name)              (PACASES Number)

 I verify that the statements made in this Income Statement are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S.A. §  4904 relating to unsworn falsification to authorities.
Date:

 SUPPLEMENTAL INCOME STATEMENT

  (a) This form is to be filled out by a person (check one):

   (1) who operates a business or practices a profession, or

   (2) who is a member of a partnership or joint venture, or

   (3) who is a shareholder in and is salaried by a closed corporation or similar entity.

  (b) Attach to this statement a copy of the following documents relating to the partnership, joint venture, business, profession, corporation or similar entity:

   (1) the most recent Federal Income Tax Return, and

   (2) the most recent Profit and Loss Statement.

  (c) Name of business:

Address and
Telephone Number:

---

---

(d) Nature of business (check one)	(e) Name of accountant, controller or other person in charge of financial records:
(1) partnership
(2) joint venture
(3) profession	(f) Annual income from business:
(4) closed corporation
(5) other	(1) How often is income received?
	(2) Gross income per pay period:
	(3) Net income per pay period:
	(4) Specified deductions, if any:

   (2)  Expense Statements. An Expense Statement is not required in cases which can be determined pursuant to the guidelines unless a party avers unusual needs and expenses that may warrant a deviation from the guideline amount of support pursuant to Rule 1910.16-5 or seeks an apportionment of expenses pursuant to Rule 1910.16-6. (See Rule 1910.11(c)(1)). Child support is calculated under the guidelines based upon the net incomes of the parties, with additional amounts ordered as necessary to provide for child care expenses, health insurance premiums, unreimbursed medical expenses, mortgage payments and other needs, contingent upon the obligor’s ability to pay. The Expense Statement in subparagraph (A) below shall be utilized if a party is claiming that he or she has unusual needs and unusual fixed expenses that may warrant deviation or adjustment in a case determined under the guidelines. In cases which must be determined pursuant to Melzer v. Witsberger, 505 Pa. 462, 480 A.2d 991 (1984), because the parties’ combined net monthly income exceeds $20,000 per month, the parties must complete the Expense Statement in subparagraph (B) below.

   (A)  Guidelines Expense Statement. If the combined monthly net income of the parties is $20,000 or less, it is not necessary to complete this form unless a party is claiming unusual needs and expenses that may warrant a deviation from the guideline amount of support pursuant to Rule 1910.16-5 or seeks an apportionment of expenses pursuant to Rule 1910.16-6. At the conference, each party must provide receipts or other verification of expenses claimed on this statement. The Guidelines Expense Statement shall be substantially in the following form.

EXPENSE STATEMENT OF

    (Name)        (PACSES Number)

 I verify that the statements made in this Expense Statement are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S.A. §  4904 relating to unsworn falsification to authorities.

 Date:

 (B)  Melzer Expense Statement. No later than five business days prior to the conference, the parties shall exchange this form, along with receipts or other verification of the expenses set forth on this form. Failure to comply with this provision may result in an appropriate order for sanctions and/or the entry of an interim order based upon the information provided.

EXPENSE STATEMENT OF

    (Name)        (PACSES Number)

 I verify that the statements made in this Expense Statement are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S.A. §  4904 relating to unsworn falsification to authorities.

 Date:

 (d)  The form used to obtain information relating to health insurance coverage from a party shall be in substantially the following form:

 (Caption)
HEALTH INSURANCE COVERAGE INFORMATION
REQUIRED BY THE COURT
This form must be completed and returned to the
domestic relations section.
IF YOU FAIL TO PROVIDE THE INFORMATION
REQUESTED, THE COURT MAY FIND
THAT YOU ARE IN CONTEMPT OF COURT.

   Do you provide insurance coverage for the dependents named below? (Check each type of insurance which you provide).

	Type of Coverage
Full Name SS #	Hospital- ization	Medical	Dental	Eye	Prescrip- tion	Other

 Note: Before forwarding the form to the party, the domestic relations section should fill in the names and Social Security numbers of the dependents about whom the information is sought.

 Provide the following information for all types of insurance you maintain, whether or not any of the above-named dependents is covered at this time:

   Insurance company (provider):

   Insurance company (provider):

   Insurance company (provider):

   Insurance company (provider):

 If the above-named dependents are not currently covered by insurance, please state the earliest date coverage could be provided.

 (e)  The form of a support order shall be substantially as follows:

 (Caption)

 (FINAL)  (TEMPORARY) (MODIFIED)
ORDER OF COURT

   AND NOW,

   For the support of:

   Said money to be turned over by the domestic relations section to:

   Payments must be made (STATE ACCEPTABLE FORMS OF PAYMENT). All checks and money orders must be made payable to (NAME OF ENTITY TO WHOM CHECKS SHOULD BE MADE PAYABLE) and mailed to (NAME OF OFFICE) at (MAILING ADDRESS). Each payment must bear your (FILE/CASE/FOLIO/DOMESTIC RELATIONS) number in order to be processed. Do not send cash by mail.

   Unreimbursed medical expenses are to be paid

 IMPORTANT LEGAL NOTICE

   PARTIES MUST WITHIN SEVEN DAYS INFORM THE DOMESTIC RELATIONS SECTION AND THE OTHER PARTIES, IN WRITING, OF ANY MATERIAL CHANGE IN CIRCUMSTANCES RELEVANT TO THE LEVEL OF SUPPORT OR THE ADMINISTRATION OF THE SUPPORT ORDER, INCLUDING, BUT NOT LIMITED TO, LOSS OR CHANGE OF INCOME OR EMPLOYMENT AND CHANGE OF PERSONAL ADDRESS OR CHANGE OF ADDRESS OF ANY CHILD RECEIVING SUPPORT. A PARTY WHO WILLFULLY FAILS TO REPORT A MATERIAL CHANGE IN CIRCUMSTANCE MAY BE ADJUDGED IN CONTEMPT OF COURT, AND MAY BE FINED OR IMPRISONED.

   PENNSYLVANIA LAW PROVIDES THAT ALL SUPPORT ORDERS SHALL BE REVIEWED AT LEAST ONCE EVERY THREE (3) YEARS IF SUCH A REVIEW IS REQUESTED BY ONE OF THE PARTIES. IF YOU WISH TO REQUEST A REVIEW AND ADJUSTMENT OF YOUR ORDER, YOU MUST DO THE FOLLOWING: AN UNREPRESENTED PERSON WHO WANTS TO MODIFY (ADJUST) A SUPPORT ORDER SHOULD (insert instructions for local domestic relations section).

   ALL CHARGING ORDERS FOR SPOUSAL SUPPORT AND ALIMONY PENDENTE LITE, INCLUDING UNALLOCATED ORDERS FOR CHILD AND SPOUSAL SUPPORT OR CHILD SUPPORT AND ALIMONY PENDENTE LITE, SHALL TERMINATE UPON THE DEATH OF THE PAYEE.

   A MANDATORY INCOME ATTACHMENT WILL ISSUE UNLESS THE DEFENDANT IS NOT IN ARREARS IN PAYMENT IN AN AMOUNT EQUAL TO OR GREATER THAN ONE MONTH’S SUPPORT OBLIGATION AND (1) THE COURT FINDS THAT THERE IS GOOD CAUSE NOT TO REQUIRE IMMEDIATE INCOME WITHHOLDING; OR (2) A WRITTEN AGREEMENT IS REACHED BETWEEN THE PARTIES WHICH PROVIDES FOR AN ALTERNATE ARRANGEMENT.

   DELINQUENT ARREARAGE BALANCES MAY BE REPORTED TO CREDIT AGENCIES. ON AND AFTER THE DATE IT IS DUE, EACH UNPAID SUPPORT PAYMENT SHALL CONSTITUTE A JUDGMENT AGAINST YOU.

   IT IS FURTHER ORDERED that, upon payor’s failure to comply with this order, payor may be arrested and brought before the Court for a Contempt hearing; payor’s wages, salary, commissions, and/or income may be attached in accordance with law; this Order will be increased without further hearing to $

   Copies delivered to parties

 (f)  A petition for modification of support shall be in substantially the following form:

 (Caption)

 PETITION FOR MODIFICATION
OF AN EXISTING SUPPORT ORDER

   1. The petition of

   2. Petitioner is entitled to

 WHEREFORE, Petitioner requests that the Court modify the existing order for support.

 I verify that the statements made in this complaint are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. §  4904 relating to unsworn falsification to authorities.

 (g)  The order to be attached at the front of the petition for modification set forth in subdivision (f) shall be in substantially the following form:

 (Caption)

 ORDER OF COURT

 You,

 You are further ordered to bring to the conference

   (1)  a true copy of your most recent Federal Income Tax Return, including W-2s, as filed,

   (2)  your pay stubs for the preceding six months,

   (3)  the Income and Expense Statement attached to this order, completed as required by Rule 1910.11(c),

   (4)  verification of child care expenses, and

   (5)  proof of medical coverage which you may have, or may have available to you.

 THE APPROPRIATE COURT OFFICER MAY MODIFY OR TERMINATE THE EXISTING ORDER IN ANY MANNER BASED UPON THE EVIDENCE PRESENTED.
Date of Order:

  YOU HAVE THE RIGHT TO A LAWYER, WHO MAY ATTEND THE CONFERENCE AND REPRESENT YOU. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIBIBLE PERSONS AT A REDUCED FEE OR NO FEE.

 AMERICANS WITH DISABILITES ACT OF 1990

 The Court of Common Pleas of

   The support complaint and Income and Expense Statements contain a verification which states that the documents are subject to the penalties of the Crimes Code relating to unsworn falsification to authorities. A notary public is not needed.

   Rule 1910.27(c) is amended to separate income and expense information and to elicit the expense information relevant in cases that fall within the guidelines, as well as those that do not. In cases which can be determined under the guidelines, no expense information need be provided unless a party is claiming unusual needs and expenses that may warrant a deviation pursuant to Rule 1910.16-5 or an apportionment of expenses pursuant to Rule 1910.16-6. If a party is claiming such expenses, the form at subsection (c)(2)(A) should be submitted. A separate expense form for cases in which the parties’ combined monthly net income exceeds $20,000 is set forth at subsection (c)(2)(B).

   Rule 1910.11(c) was amended, effective in March 1995, to provide that only income and extraordinary expenses need be shown on the Income and Expense Statement in cases which can be determined pursuant to the guidelines. The Explanatory Comment—1994 explained the rationale for the amendment.

   Nevertheless, because space for both income and expense information was provided on the same form Income and Expense Statement, parties often needlessly expended time and effort to provide expense information that was not relevant at the conference. The amendments are intended to clarify and simplify the submission of expense information.

   The provisions of this Rule 1910.27 amended March 23, 1987, effective July 1, 1987, 17 Pa.B. 1499; amended November 7, 1988, effective January 1, 1989, 18 Pa.B. 5326; amended March 30, 1994, effective July 1, 1994, 24 Pa.B. 1953; amended December 2, 1994, effective March 1, 1995, 25 Pa.B. 6263; amended March 24, 1997, effective July 1, 1997, 27 Pa.B. 1549; amended May 31, 2000, effective July 1, 2000, 30 Pa.B. 3155; amended June 5, 2001, effective immediately, 31 Pa.B. 3306; amended June 24, 2002, effective immediately, 32 Pa.B. 3389; amended March 18, 2004, effective June 16, 2004, 34 Pa.B. 1754; amended November 8, 2006, effective February 6, 2007, 36 Pa.B. 7113. Immediately preceding text appears at serial pages (267755) to (267756), (303573) to (303574), (267759) to (267762), (281435) to (281436) and (303575) to (303577).