Form Csed 04-1603 - Child Support Information Form Page 4
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4COMPLETE ONLY IF YOU MARKED BOX 2 ON PAGE ONE
NONDISCLOSURE OF IDENTIFYING INFORMATION AFFIDAVIT
I, ______________________________________________, swear under penalty of perjury that the following information is true to the
best of my knowledge and belief.
1.
Name of Obligor and Child Support Enforcement Case Number:
___________________________________________
____________________________________________
2. Who will be protected by withholding identifying information? Please list your name and your child(ren)’s names:
____________________________________________
______________________________________________
____________________________________________
______________________________________________
____________________________________________
______________________________________________
3. Have you or your child(ren) ever felt threatened by harassment, threats, mental or emotional abuse, or physical violence, including
sexual assault or incest? Please explain when you felt this way, and describe who was involved, when, where, and how it happened.
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
4.
Is there a restraining order in effect now for domestic violence?
_____Yes
_____No
If yes, include a copy when you return this form. Case number _____________________________________
Court/judicial district ______________________________
5.
Was there a restraining order in the past for domestic violence ? _____Yes
_____No
If yes, please write the case number and information about the case below, such as who was involved, when, where, and how it
happened.
Case number _____________________________________
Court/judicial district ______________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
6.
Were you ever involved in a criminal assault case with the other party as the defendant?
_____Yes
_____No
If yes, please write the case number and information about the case below, such as who was involved, when, where, and how it
happened.
Case number _____________________________________
Court/judicial district______________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
7.
Is there any other information you can give to show why you feel threatened by the other party in your child support case?
______________________________________________________________________________________________
______________________________________________________________________________________________
_________________________________
_______________________________________________________________
Signed
Date
SUBSCRIBED and SWORN to before me this _________ day of ______________________________, 20 ______
_________________________________________________________________
Notary Public for the State of _______________________
My commission expires: ___________________________
Witness (Print Name)_______________________________________________________________________________________________
Witness Signature______________________________________________________________ Date Signed_________________________
Witness Address__________________________________________________________________________ Zip Code______________
Telephone #______________________________________ Social Security # (Optional) _________________________________________
I willingly state that I know the person who has signed this form to be the person that he/she states he/she is and I have witnessed their signature on this form.
CSED 04-0502b (Rev 10/14/1998)
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