Simplified Application For Child Support Services Page 4
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4FACTS ABOUT NONCUSTODIAL PARENT
TRIBAL MEMBER NAME OF TRIBE
FULL NAME (LAST, FIRST, MIDDLE)
YES
NO
RELATIONSHIP TO CHILD(REN)
TELEPHONE NUMBERS
MAIDEN NAME (IF APPROPRIATE)
HOME:
FATHER
NAME OF CURRENT SPOUSE
WORK:
MOTHER
CELL:
OTHER NAMES OR ALIASES OF NONCUSTODIAL PARENT
E-MAIL ADDRESS
ADDRESS (STREET, CITY, STATE AND ZIP CODE)
CURRENT NOW
CURRENT AS OF (DATE)
SOCIAL SECURITY NUMBER DRIVERS LICENSE NUMBER STATE BIRTHDATE OR APPROXIMATE
PLACE OF BIRTH
GENDER
AGE
FEMALE
MALE
Currently on probation or parole?
YES
NO
Currently in jail or prison?
If "YES", provide information below:
YES
NO
DATE
AGENCY
CITY
STATE
OFFENSE (REASON)
Is the noncustodial parent a US citizen?
YES
NO
IF "NO", Please provide country of citizenship here:
PHYSICAL DESCRIPTION: (PLEASE PROVIDE PHOTO)
RACE
COMPLEXION
PRIMARY LANGUAGE
HAIR
HEIGHT
IDENTIFYING FEATURES (MARKS, SCARS, TATTOOS, ETC.)
EYES
WEIGHT
GROSS MONTHLY
NAME OF PRESENT EMPLOYER (IF NOT WORKING, PRINT "UNEMPLOYED")
IS HEALTH
CURRENT NOW
EARNINGS
INSURANCE
AVAILABLE FOR
CURRENT AS OF
ADDRESS OF PRESENT EMPLOYER (STREET, CITY, STATE AND ZIP CODE)
$
CHILDREN?
(DATE)
YES
NO
If unemployed or present employer is unknown, give name, address and telephone number of last employment below.
NAME OF LAST EMPLOYER
ADDRESS OF LAST EMPLOYER (STREET, CITY, STATE AND ZIP CODE)
TELEPHONE NUMBER (INCLUDE
AREA CODE)
USUAL OCCUPATION, TRADE, JOB TITLE OR SKILLS
ACTIVE MILITARY:
YES
NO
WHAT BRANCH OF THE SERVICE?
IS THE NONCUSTODIAL PARENT A LABOR UNION
NAME AND NUMBER OF UNION
ADDRESS OF UNION (STREET, CITY, STATE AND
ZIP CODE)
MEMBER?
YES
NO
IF SELF-EMPLOYED, WHAT IS THE NAME OF THE BUSINESS?
GROSS MONTHLY EARNINGS
$
STEADY WORKER?
YES
NO
IF NO, EXPLAIN:
List any other sources of income or assets. (For example, Veterans Affairs benefits, Social Security Disability, interest, dividends, trust,
vehicles, boats, real estate, etc. Attach a separate sheet if necessary).
MOTHER'S MAIDEN NAME (LAST, FIRST)
MOTHER'S STREET ADDRESS, CITY, STATE AND ZIP CODE
MOTHER'S TELEPHONE
NUMBER
FATHER'S NAME (LAST, FIRST)
FATHER'S STREET ADDRESS, CITY, STATE AND ZIP CODE
FATHER'S TELEPHONE
NUMBER
Name and address of current spouse, friend, or relative.
NAME
RELATIONSHIP
STREET ADDRESS, CITY, STATE ZIP CODE
TELEPHONE NUMBER
Is there visitation with the children?
YES
NO
If "YES", how many times per month?
If "YES", please provide amount: $
Is there any other child support obligation(s)?
YES
NO
Is there any other minor child(ren) in the home?
YES
NO
If "YES", how many children?
Present marital status:
Single
Married
Divorced
Separated
Living with another person
I request the services of the Department of Child Support Services to assist me in the following efforts: (Mark all that apply)
No medical insurance enforcement
Establish paternity
Modify an existing child support order
needed at this time. The children have
Obtain a child support order
Obtain an order for medical insurance
satisfactory medical insurance
Enforce an existing child and spousal
Enforce an existing medical insurance
coverage through:
Custodial Parent
support order (including past due)
order
Noncustodial Parent
I am applying for support services under the Child Support Program of Title IV-D of the Social Security Act. I declare under penalty of
perjury (Penal Code, Section 118) that this questionnaire has been examined by me and to the best of my knowledge and belief it is true and
correct.
DATE
SIGNATURE OF APPLICANT
Page 3 of 3
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