IN THE COURT OF COMMON PLEAS OF PHILADELPHIA COUNTY, PENNSYLVANIA
	,	:
Plaintiff		:	FAMILY COURT DIVISION
		:
	vs.	:
		:
	,	:
Defendant		:	PACSES NO.
		:
COMPLAINT FOR SUPPORT
1.	The plaintiff is (name) _____________________________________________________________
and resides at (street, city, state, zip) ______________________________________________________
___________________________________________________________________________________.
Plaintiff’s Social Security Number is ______________________, and date of birth is ________________.
2.	The defendant is (name) ___________________________________________________________
and resides at (street, city, state, zip) ______________________________________________________
___________________________________________________________________________________.
Defendant’s Social Security Number is _____________________, and date of birth is _______________.
3.	Plaintiff and Defendant are/were/were never (cicle one) married.
4.	The parties are the parents of (fill in number) ______ children. The names, birth dates and residence of the child/ren are:
Name: _____________________________________________ Birth Date: _______________________
Address: ____________________________________________________________________________
Name: _____________________________________________ Birth Date: _______________________
Address: ____________________________________________________________________________
Name: _____________________________________________ Birth Date: _______________________
Address: ____________________________________________________________________________
Name: _____________________________________________ Birth Date: _______________________
Address: ____________________________________________________________________________
Name: _____________________________________________ Birth Date: _______________________
Address: ____________________________________________________________________________
Name: _____________________________________________ Birth Date: _______________________
Address: ____________________________________________________________________________
5.	Plaintiff seeks support for the following persons:

	
6.	Plaintiff (circle one) is/is not receiving public assistance. 
7.	The last support received from the Defendant was ____________________ on __________.
	WHEREFORE, Plaintiff requests that an order be entered against Defendant and for Plaintiff and/or the aforementioned child/ren for reasonable support and medical coverage.
Date: _________________________________		
	Plaintiff
VERIFICATION
	I, ___________________________________, verify that the statements made in the foregoing Complaint for Support 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.
Date: _________________________________		
	Plaintiff