Child Support Case Registration And Payment Form (Css-1)
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1
2RHODE ISLAND FAMILY COURT, ONE DORRANCE PLAZA, PROVIDENCE, RI 02903
CHILD SUPPORT CASE REGISTRATION
AND PAYMENT FORM (CSS-1)
PURSUANT TO RIGL 15-5-16.2(
) THIS FORM MUST BE COMPLETED IN FULL FOR ALL NEW, MODIFIED OR
H
SUSPENDED SUPPORT ORDERS REGARDLESS OF WHETHER PAYMENTS ARE TO BE MADE
THROUGH RI FAMILY COURT
PLEASE NOTE THERE ARE TWO (2) SIDES TO THIS FORM
DOMESTIC DOCKET # _________________ RECIPROCAL DOCKET # ______________________ Merged Yes / No
OBLIGOR ---- NON-CUSTODIAL PARENT( NCP)
OBLIGEE ---- CUSTODIAL PARENT (CP)
Check One [ ] Plaintiff
[ ] Defendant
Check one [ ] Plaintiff
[ ] Defendant
NAME:
NAME:
_______________ ____ ___________________________ ____
_________________ _____ ________________________ ______
FIRST
MI
LAST
Mod
FIRST
MI
LAST
Mod
ADDRESS: _________________________________________________________
ADDRESS: ___________________________________________________________
CITY/STATE__________________________________________ZIP: __________
CITY/STATE__________________________________________ZIP: ___________
DOB: _____________ SEX: _______
SSN:_____________________________
DOB: __________ SEX: ______ SSN:____________________________________
CELL PH # _______________________ HOME PH # ________________________
CELL PH # _______________________ HOME PH # ________________________
OBLIGEE’S ATTY:____________________________________________________
DRIVER’S LICENSE # __________________________________(IF KNOWN)
ATTY BAR # _________________ PHONE#________________________________
OBLIGOR’S ATTY: __________________________________________________
ATTY BAR # _________________ P
# _____________________________
HONE
EMPLOYMENT INFORMATION - OBLIGOR
NON DISCLOSURE OF INFORMATION
DUE TO FAMILY VIOLENCE ( FVI ) **
____________________________________________________________________
COMPLETE THIS
SECTION ONLY IF THERE IS A HISTORY OF FAMILY VIOLENCE
EMPLOYER NAME
RIGL 15-22-4
AS DEFINED IN
____________________________________________________________________
[
] NON-DISCLOSURE OF INFORMATION ON THE IV-D SYSTEM
ADDRESS
IS REQUESTED DUE TO DOMESTIC VIOLENCE -
I
_______________________________________________ ___________________
CLAIM THE DISCLOSURE OF MY ADDRESS OR OTHER IDENTIFYING
(
)
CITY
STATE
ZIP
PHONE
INFORMATION COULD BE HARMFUL TO ME OR THE CHILD
REN
IN MY CARE
RIGL 15-22-4
AS THERE IS A HISTORY OF FAMILY VIOLENCE AS DEFINED IN
EMPLOYMENT INFORMATION – OBLIGEE
WHOSE ADDRESS IS TO BE PROTECTED?
___________________________________________________________________
[
] OBLIGEE / CHILDREN
[ ] OBLIGOR
EMPLOYER NAME
**C
FVI
HECKING THE
BOX PREVENTS DISCLOSURE OF CERTAIN
___________________________________________________________________
IV-D C
IDENTIFYING INFORMATION IN CONNECTION WITH THE
HILD
ADDRESS
S
ONLY. T
FVI
F
C
UPPORT PROGRAM
HE
DOES NOT SEAL THE
AMILY
OURT
F
;
FVI
R
O
O
________________________________________________ __________________
ILE
THE
IS NEITHER A
ESTRAINING
RDER NOR AN
RDER FOR
CITY
STATE
ZIP
PHONE
P
. Y
S
M
S
C
ROTECTION
OU MUST FILE A
EPARATE
OTION TO
EAL THE
OURT
F
.
ILE IF YOU WANT THAT INFORMATION PROTECTED
NAMES OF DEPENDENT CHILDREN
(ATTACH ADDITIONAL SHEET IF MORE THAN THREE CHILDREN)
CHILD’S NAME
SEX
DOB
SOCIAL SECURITY #
HEALTH INS THRU:
Circle all that apply
CP
NCP
STATE
1 ____________________ ____ ___________________________________
M / F
____________ _______________________
FIRST
MI
LAST
Mod
CP
NCP
STATE
2 ____________________ ____ ___________________________________
M / F
____________
_______________________
FIRST
MI
LAST
Mod
CP
NCP
STATE
3 ____________________ ____ ___________________________________
M / F
___________
_______________________
FIRST
MI
LAST
Mod
HEALTH INSURACE CODES
CP= C
P
’
NCP= N
C
P
’
STATE=
:
USTODIAL
ARENT
S
ON
USTODIAL
ARENT
S
INSURANCE IS PROVIDED BY ONE OF FOLLOWING
E
E
RITECARE / RITESHARE / RIWORKS
MPLOYER SPONSORED PLAN
MPLOYER SPONSORED PLAN
S
WITH OR WITHOUT
TATE SUBSIDY
WITH OR WITHOUT STATE SUBSIDY
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