Custodial Party Case Information Worksheet
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1
2
3
4CUSTODIAL PARTY (CP)
To be completed by County Office:
CASE INFORMATION WORKSHEET
DHR File No.
Case ID
(Please use pen and print or write legibly.)
CP ID
NCP ID
CP Name
NCP Name
APPLICANT DATA (Person providing care for children)
Full name (first, middle, and last)
Maiden/Alias
Social Security Number
Sex
Race
Date of birth (month, day, year)
Current marital status:
Married
Divorced
Separated
Deserted
Never married
Unknown
Street address (street or rural route number and box)
A
D
City
State
Zip
Phone number (area code + number)
D
R
E
Mailing Address
Mailing address is:
Same as above
S
Different (Complete mailing address)
S
City
State
Zip
E
Employer Name
Address
M
P
L
City
State
Zip
Phone number (area code + number)
O
Y
E
If “Yes,” at what cost to you?
Is dependent coverage available
If “Yes,” do you provide coverage?
Medical Insurance:
R
through your employer?
Yes
Yes
No
N
Address of someone who will always know how to contact you:
Name
Relationship
Phone number (area code + number)
Address
City
State
Zip
If “Yes” give month and year of last check
County/State where AFDC was received
Have you ever received an AFDC check?
Yes
No
Have any of the children you are applying for ever received SSI benefits?
Yes
No If “Yes,” list the name(s) of the child(ren).
If “Yes” give month and year of last
County/State where Medicaid was
Have you or your children ever received Medicaid?
Yes
benefits
received
No
Are you receiving help with or being represented in the matter of child support by an attorney or other agency?
Yes
No
If “Yes,” give name and address of attorney or agency.
Address
City
State
Zip
Phone number (area code +
number)
CHILD DATA
CHILD’S FULL NAME
SEX BIRTHDATE
PLACE OF BIRTH
SOCIAL SECURITY
RELATIONSHIP
LEGAL
(
(
.)
(
)
NUMBER
TO YOU
FATHER
FIRST, MIDDLE, LAST)
MO., DAY, YR
CITY, STATE
YES /
NO
YES /
NO
YES /
NO
YES /
NO
YES /
NO
YES /
NO
YES /
NO
YES /
NO
If all of the children listed above do not live with you, please provide the addresses of those children in the comment section on page four.
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