Non Iv-D Case Registration Form - Georgia Department Of Human Services printable pdf download

Georgia Department of Human Services

NON IV-D CASE REGISTRATION FORM

(Used in private child support cases)

Submit this form to the Family Support Registry

(Pursuant to O.C.G.A. § 19-6-33.1)

Complete ALL fields – otherwise, the case cannot be registered and money cannot be distributed.

Non-Custodial (Paying) Parent

Custodial (Receiving) Parent

Name: __________________________________________

Address: ________________________________________

________________________________________________

DOB: _____/_____/__________ Gender: [ ] M [ ] F

SSN: _______-_____-__________ Race: ______________

Ethnicity:

[ ] Hispanic

[ ] Non-Hispanic

Ethnicity:

[ ] Hispanic

[ ] Non-Hispanic

Telephone #: _____________________________________

Telephone #: ______________________________________

Non-Custodial Parent’s Employer: ________________________________________________________________________

Address: ______________________________________________________________________________________________

______________________________________________________________________________________________________

Employer’s Telephone #: ________________________________________________________________________________

Court Order Information

County/State of Order: _________________________________ Civil Action Number: ____________________________

Date Order Signed: _____/_____/__________

First Due Date: _____/_____/__________

Child Support Order Amount: $____________________ per ____________________

Court adjudicated arrears amount: $____________________ as of _____/_____/__________

Is this an order modifying child support?

[ ] Yes

[ ] No

Children for Whom Child Support Is Ordered

Child’s full name

DOB

Gender

SSN

Race

Ethnicity (Hispanic

or Non-Hispanic)

_________________________ ___/___/____

[ ] M [ ] F _____-_____-______

_____________

_______________

_________________________ ___/___/____

[ ] M [ ] F _____-_____-______

_____________

_______________

_________________________ ___/___/____

[ ] M [ ] F _____-_____-______

_____________

_______________

_________________________ ___/___/____

[ ] M [ ] F _____-_____-______

_____________

_______________

Mail OR Fax this completed form along with a copy of the Income Deduction Order that was signed by a

judge. Please DO NOT Mail AND Fax the documents or else it will delay the distribution of child support.

Mail to:

Family Support Registry

P. O. Box 1800

Carrollton, Georgia 30112-1800

Fax to: 770-836-2701 (Do not mail the documents if you fax them.)

Georgia Family Support Registry, Non-IV-D Case Registration Form

Last Update: August 23, 2012

Non Iv-D Case Registration Form - Georgia Department Of Human Services

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