PLEASE READ THE FOLLOWING INSTRUCTIONS CAREFULLY
BEFORE COMPLETING THE PAPERWORK ATTACHED.
WHO CAN FILE FOR SUPPORT?
•
•
•
You can file for support if you are 18 years of age or older for yourself and/or a child in your
physical custody;
o If you are a minor, you can still file for support however a parent or guardian must
accompany you to all support appointments, conferences and hearings;
You can file for support for yourself if you are married, regardless of your age;
You can file for support for a child with a disability regardless of the age of the child.
The Butler County Domestic Relations Section is linked to a statewide child support system known as
PACSES. The information you provide today will not only help this office in properly setting up your
case, but will also help with future developments of your case.
Domestic Relations must have the information we are requesting of you now to establish your
case. When possible, the DRS may attempt to obtain and confirm information over the telephone in
an effort to avoid delaying your application for support services or to keep you from having to appear
for an appointment. Once all correct information is received, Domestic Relations will establish your
case and schedule a conference if required. You will be notified by Court Order of the date and time
to appear. If further information is needed, you will be contacted for a possible appointment.
If you desire to have an attorney present, it will be your responsibility to notify your attorney of the
date and time of the support conference.
FOR OFFICE USE ONLY:
PTS
 YES
DPW 643
 NO
 YES
LOCATION INFO. FORM
 NO
 YES
 NO
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BUTLER COUNTY DOMESTIC RELATIONS SECTION
You are the PLAINTIFF, if you are the person filing for support. The person you are filing against is
the DEFENDANT.
*PLEASE PRINT LEGIBLY*
GENERAL INFORMATION:
What is your relationship to the Defendant? (Check only one box and then only answer those
questions under the box you checked.)
 Spouse or  ex-spouse
Date of Marriage
City & State of marriage
Date of Separation
Date of Divorce
City & State of Divorce
Address of last marital
residence
 Never Married (Boyfriend/Girlfriend, Sexual partner, etc.)

Relative/Third-party
Relationship to the defendant?
_________________
Relationship to the children for whom you are seeking support? (Are you a
grandparent, aunt, uncle, friend, other?)
___________
List the names of ALL persons for whom you are applying for support, including yourself if you're
filing for spousal support. Use the back of this page if necessary.
Full legal name(s)
SS#
Date of Birth
1. ___________________________________________________________________________
2. ___________________________________________________________________________
3. ___________________________________________________________________________
4. ___________________________________________________________________________
5. ___________________________________________________________________________
6. ___________________________________________________________________________
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The person you are filing against is the DEFENDANT. Please answer completely all of the following
questions about the Defendant:
*PLEASE PRINT LEGIBLY*
Print the Defendant’s full legal name as it appears on his/her driver’s license:
_________________________________________________________________________________
First
Middle
(Maiden)
Last
Jr/Sr/II/III
Does the Defendant have a nickname? If yes, list here:
____________________________________________
Print the Defendant’s addresses (include street address, city, state, zip, and county):
Mailing address:
Physical address:
________________________________________________
________________________________________________
________________________________________________
City
State
Zip
County
________________________________________________
City
State
Zip
County
Social Security #:
Date of Birth:
Home Phone:
Cell Phone:
Other Contact #:
E-mail Address:
Description of the Defendant:
Male  Female  Race _____ Eyes ______ Hair _____ Height ___’ ___” Weight _______
Any Distinguishing marks (scars, tattoos, etc.)?______________________________________ ___
Is the Defendant active in any Branch of the Military Service? _____________________________
If yes, what Branch? ___________________________________ Rank:
Name, address, and phone number of Defendant’s employer or source of income
(SSD/UC/Worker’sComp)
________________________________________________________________________________
_________________________________________________________________________________
Name and address of employer’s payroll department if different from above:
________________________________________________________________________________
__________________________________________ Pay Frequency: _______________________
Name, address, and phone number of Defendant’s Parents:
________________________________________________________________________________
_________________________________________________________________________________
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You are the PLAINTIFF, or the person filing for support. Please answer completely all of the
following questions:
Print your full legal name as it appears on your driver’s license:
________________________________________________________________________________
First
Middle
(Maiden)
Last
Jr/Sr/II/III
Print your mailing address:
(include street address, city, state, zip, and county)
Do you physically reside someplace other than
your mailing address? If yes, list address:
________________________________________________
________________________________________________
________________________________________________
City
State
Zip
County
________________________________________________
City
State
Zip
County
Social Security #:
Date of Birth:
Home Phone:
Cell Phone:
Other Contact #:
E-mail Address:
Description:
Male  Female  Race ______ Eyes ______ Hair _____ Height ___’ ___” Weight ______
City & State of birth: _____________________________________________________________
Your Mother’s Name: ____________________________________________________________
(First)
(Middle Initial)
(Maiden Last Name)
Is she living or deceased? _______________ If living, provide address & phone number:
_______________________________________________________________________________
_______________________________________________________________________________
Your Father’s Name:______________________________________________________________
(First)
(Middle Initial)
(Last Name)
Is he living or deceased? ________________If living, provide address & phone number:
_______________________________________________________________________________
_______________________________________________________________________________
What is your occupation? ________________________________________________________
List the name of your employer:______________________________________________________
What is your employer's address? ____________________________________________________
_______________________________________________________________________________
What is your employer's phone number?_______________________________________________
List the address where payroll information may be obtained from your current employer.
_______________________________________________________________________________
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How long have you worked for your current employer? ___________________________________
Are you active in any Branch of the Military Service? Yes  No 
If yes, what branch?_________________________ What Rank? ___________________
Do you have a current PA Driver’s License? Yes 
No 
What is your driver’s license number? (the number that appears directly above your picture)
_______________When was this license issued? ___________ When will it expire?___________
Are you currently in receipt of cash assistance? Yes  No 
If Yes, what is your DHS #?_________________________
Other person to contact besides parents: (indicate relationship, name, address, & phone #)
________________________________________________________________________________
________________________________________________________________________________
Is there an active support order in existence anywhere for this child/children?
Yes No
If yes, where? ____________________________ (County/State/Country)
Is there a closed support order in existence anywhere for this child/children?
Yes No
If yes, where? ____________________________ (County/State/Country)
Have you ever filed to receive support for this child/children?
Yes No
If yes, where? ____________________________ (County/State/Country)
Are you receiving spousal support/Alimony/APL from this defendant through a court order?
Yes No
If yes, where? ____________________________ (County/State/Country)
Does the Defendant have any other support cases of which you are aware?
Yes No
If yes, in what city & state?
Other Court Identifying Number:
Do you or have you ever had a Protection From Abuse Order against this Defendant?
Yes No
* If yes, in what county was the Protection From Abuse Order entered?
* Is the Protection From Abuse Order against the Defendant still active?
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Yes No
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Complete the following information for the CHILDREN for whom you are seeking support.
Child #1
Child’s Full Legal Name:
M
Street Address:
Social Security Number:
DOB:
Is this child covered by any insurance at this time? Yes
No
Does this child have any extraordinary medical expenses? Yes
If yes, explain


F


 No
No
Was this child born of the marriage between you and the defendant? Yes
In what hospital was the child born?
In what City and State was the child born in?
What City and State was the child conceived in?
__________
If this child WAS NOT born of the marriage between you and the Defendant, please answer the
following questions:
Has paternity ever been established for this child, either through Court Order, genetic testing,
acknowledgment signed at the hospital? Yes
No


 
Were you married to anyone at the time this child was conceived or born? Yes No
If yes, name of person
Do you have a Court Order saying that the person you were married to when the child was
conceived/born is NOT the father? Yes
No


Child #2
Child’s Full Legal Name:
M
Street Address:
Social Security Number:
DOB:
Is this child covered by any insurance at this time? Yes
No
Does this child have any extraordinary medical expenses? Yes
If yes, explain


F


 No
No
Was this child born of the marriage between you and the defendant? Yes
In what hospital was the child born?
In what City and State was the child born in?
What City and State was the child conceived in?
__________
If this child WAS NOT born of the marriage between you and the Defendant, please answer the
following questions:
Has paternity ever been established for this child, either through Court Order, genetic testing,
acknowledgment signed at the hospital? Yes
No


 
Were you married to anyone at the time this child was conceived or born? Yes No
If yes, name of person
Do you have a Court Order saying that the person you were married to when the child was
conceived/born is NOT the father? Yes
No


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Child #3
Child’s Full Legal Name:
M
Street Address:
Social Security Number:
DOB:
Is this child covered by any insurance at this time? Yes
No
Does this child have any extraordinary medical expenses? Yes
If yes, explain


F


 No
No
Was this child born of the marriage between you and the defendant? Yes
In what hospital was the child born?
In what City and State was the child born in?
What City and State was the child conceived in?
__________
If this child WAS NOT born of the marriage between you and the Defendant, please answer the
following questions:
Has paternity ever been established for this child, either through Court Order, genetic testing,
acknowledgment signed at the hospital? Yes
No


 
Were you married to anyone at the time this child was conceived or born? Yes No
If yes, name of person
Do you have a Court Order saying that the person you were married to when the child was
conceived/born is NOT the father? Yes
No


Child #4
Child’s Full Legal Name:
M
Street Address:
Social Security Number:
DOB:
Is this child covered by any insurance at this time? Yes
No
Does this child have any extraordinary medical expenses? Yes
If yes, explain


F


 No
No
Was this child born of the marriage between you and the defendant? Yes
In what hospital was the child born?
In what City and State was the child born in?
What City and State was the child conceived in?
__________
If this child WAS NOT born of the marriage between you and the Defendant, please answer the
following questions:
Has paternity ever been established for this child, either through Court Order, genetic testing,
acknowledgment signed at the hospital? Yes
No


 
Were you married to anyone at the time this child was conceived or born? Yes No
If yes, name of person
Do you have a Court Order saying that the person you were married to when the child was
conceived/born is NOT the father? Yes
No


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ATTENTION:
Please make sure that
all lines containing an “X”
are completed and/or signed
on the following pages!
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V.
PACSES Case Number:
There  are  are no arrears in the amount of $
.
The order  has  has not been terminated.
Plaintiff last received support from the Defendant in the amount of $
.
on
WHEREFORE, Plaintiff requests that an order be entered against the Defendant and in favor of the Plaintiff
and the aforementioned child(ren) for reasonable support and medical coverage.
________________
Date
X
_____________________________________________________
Plaintiff or Attorney for Plaintiff Signature
I verify that the statements made in this Complaint are true and correct. I understand that false
statements herein are made subject to penalties of 18 Pa. C. § 4904, relating to unsworn falsification to
authorities.
X
Plaintiff
X
Date
NOTICE
Guidelines for child and spousal support, and for alimony pendent lite, have been prepared by the Court of
Common Pleas and are available for inspection in the Office of the Domestic Relations Section:
124 West Diamond Street
Butler, PA 16001
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In the Court of Common Pleas of Butler County, Pennsylvania
DOMESTIC RELATIONS SECTION
PO BOX 1208, BUTLER, PA 16003-1208
Phone: (724) 284-5181
Fax: (724) 284-5422
FULL DISCLOSURE and INFORMED CONSENT
The following disclosure and informed consent is made pursuant to and in compliance with the
provisions of the Intrastate Family Support Act, 23 Pa. C.S. Section 8101 et seq.
(1) I understand that local filing of support cases is preferable because that means that all
court proceedings will be conducted in this county. However, I understand that if I file
locally and if the Domestic Relations Section (DRS) is unable to get mail and/or Sheriff
Service on the non-custodial parent, the case will need to be re-filed under the Intrastate
Family Support Act (IFSA). If re-filing under IFSA is necessary, every effort will be made
to protect the original filing date, but some time will be lost toward the goal of getting an
order established.
(2) I understand that if I file my action under IFSA to the noncustodial parent's DRS, all
proceedings will be conducted there and the support order will be entered there.
(3) I understand that if I file my action under IFSA to the noncustodial parent's DRS, the
noncustodial parent's county court will provide legal services to me, when appropriate, at
no cost.
(4) I understand that if I file my action under IFSA to the noncustodial parent's DRS, I might
be required to submit additional information to the noncustodial parent's DRS, and I
agree to respond fully and promptly.
(5) I understand that if I file my action under IFSA to the noncustodial parent's DRS and
when an order is established in the noncustodial parent's DRS, I will be dealing directly
by phone or by mail with that county's DRS staff regarding collections and enforcement.
I further understand that I can continue to file actions to the noncustodial parent's DRS,
or obtain information through my local DRS.
 I have had the above conditions read and explained to me.
 I understand the requirement to file under IFSA and agree to the above conditions.
 I understand my option to proceed with a local filing, agree to the above condition,
and I wish to:
 File Locally
X
Date
 File IFSA
X
Custodial Parent
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In the Court of Common Pleas of Butler County, Pennsylvania
DOMESTIC RELATIONS SECTION
PO BOX 1208, BUTLER, PA 16003-1208
Phone: (724) 284-5181
Fax: (724) 284-5422
Application for Child or Spousal Support Services
(please print clearly)
I request child/spousal support services under Title IV-D of the Social Security Act, as
amended, from
BUTLER County Domestic Relations Section.
Name of applicant/custodian
(Plaintiff)
X
Social Security Number (SSN)
X
Name of non-custodial parent(s)
(Defendant)
X
X
X
Applicant Signature
Date
In accordance with Section 7(b) of the Privacy Act, you are hereby notified that
disclosure of your Social Security number is mandatory based on Section 466(a)(13) of the
Social Security Act [42 U.C.C. 666(a)(13)], Pennsylvania Consolidated Statutes (Pa C.S.)
§§4304.1 and 4353 (a.2). Additionally, you are notified that this information will be used by the
Title IV-D program to locate individuals for the purpose of establishing paternity and
establishing, modifying, and enforcing support obligations.
FOR OFFICE USE ONLY
Date rec'd in DRS
 TANF
 NON-TANF
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 IV-E
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