STATE OF SOUTH CAROLINA	)	IN THE FAMILY COURT
)	JUDICIAL CIRCUIT
COUNTY OF	)
)
)	AFFIDAVIT
Petitioner,	)	(Failure to Pay Court-Ordered Support
)	Other than Periodic Child Support)
vs.	)
)	S.C. Code Ann. § 63-17-385
)
Respondent.	)	Docket No.
Petitioner	Respondent
Name	Name
Address	Address

AFFIDAVIT

The Petitioner states under oath and respectfully alleges and shows:

The Respondent by order of the court dated , was required to pay Petitioner $ per for the child’s health medical educational

other: support, excluding periodic child support payments.

The Petitioner notified the Respondent on (date) by that the payments were not received and requested that payments be made as required by the court order.

The Petitioner did did not receive a response from the Respondent regarding the request for payments.

The support owed relates to an expense covered by an insurance policy and all documentation is attached.

This Affidavit is supported by the documents which are attached: (Check all that apply)

The court order dated requiring the Respondent to provide monetary support for the child excluding periodic child support.

A copy of the bill, invoice, or other written document listing the expense the Petitioner claims the Respondent is required to pay.

A copy of the written request for payment by Petitioner to the Respondent.

A copy of the written reply to the Petitioner from the Respondent.

Copies of all correspondence to and from the insurance carrier pertaining to payment of the insurance claim are attached.

Proof that the Petitioner has satisfied the portion of the expense he/she is required to pay.

Sworn to before me this

Day of __________________, 20 ___

Petitioner

_________________________________

Notary Public for South Carolina

My Commission Expires: ____________

Pursuant to S.C. Code Ann. § 63-17-385(C), if the family court determines that the claims or defenses of either party are frivolous, or that either party knowingly or intentionally made or filed a false authorized affidavit, or knowingly or intentionally submitted false documents in support of a claim or defense, the court may award to either party attorney’s fees and other litigation costs reasonably incurred in the prosecution or defense of the petition.

Custodial Parent (if applicable):

SCCA 457 (7/2010)

STATE OF SOUTH CAROLINA

Carolyn W Yon

2010-07-07

wclark

SCJD