Supplemental Petition to Modify Parental Responsibility · Step 5 of 6

Signature & Certification

mailed Check this box if you sent the document by regular mail. faxed and mailed Check this box if you sent the document by fax and also mailed it. e-mailed Check this box if you sent the document by e-mail. hand-delivered Check this box if you gave the document to the person in person. delivered to the person(s) listed below on {date} Enter the date you sent or delivered this document to the other party. Name: Write the full name of the other party or their attorney who got a copy. Address: Write the street address where you sent the copy. City, State, Zip: Write the city, state, and ZIP code for that address. Fax Number: Write the fax number if you sent the copy by fax. Designated E-mail Address(es): Write the e-mail address if you sent the copy by e-mail. Signature of Party Sign your name here to confirm you sent the copy. Printed Name: Print your full name clearly so it can be read. Address: Write your own street address. City, State, Zip: Write your own city, state, and ZIP code. Telephone Number: Write a phone number where you can be reached. Fax Number: Write your fax number if you have one. Designated E-mail Address(es): Write your own e-mail address for court papers. This form was prepared for the: {choose only one} Petitioner Check this box if the helper filled out the form for the Petitioner. This form was prepared for the: {choose only one} Respondent Check this box if the helper filled out the form for the Respondent. {name of individual} Write the full name of the person who helped you fill out this form. {name of business} Write the name of the business where the helper works. {address} Write the street address of the helper or their business. {city} Write the city for the helper's address. {state} Write the state for the helper's address. {zip code} Write the ZIP code for the helper's address. {telephone number} Write the phone number for the helper.

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