AFFIDAVIT IN SUPPORT OF GOOD CAUSE REQUEST

Custodial Parent

Non-Custodial Parent

Wyoming Case Number

I, _______________, hereby swear under penalty of perjury that I believe that pursuing child support services will put me and/or my children at risk of physical or emotional harm. I have been offered the following safety measures:

• Phone appearance so that I do not have to appear in courtroom with other party

• Separate meetings with child support so that I do not have to meet with the other party in person

• Assistance and support from the local domestic violence program.

• Family Violence Indicator (Preventing my address information from being disclosed by Child Support)

• Confidentiality order (Preventing the Court from releasing my address information)

Understanding that I have the right to avail myself of the above protections, I still wish to claim good cause because: (check all that apply)

Accessing paternity establishment/child support services will:

□ Put me at risk of physical harm □ Put me at risk of emotional harm

□ Put the child(ren) at risk of physical harm □ Put the child(ren) at risk of emotional harm

OR

□ Legal proceedings for the child’s adoption are pending before a court.

□ Child was conceived as a result of sexual assault or sexual abuse of a minor.

□ I am being assisted by a social service agency to decide whether to keep my child or relinquish him/her for adoption.

______________________________________ ________________________

Signature Date

Cross Reference

None