State Referral: Federal Criminal Prosecution For Non-Support Form - Project Save Our Children - Office Of Child Support Enforcement

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D Date Case Received (mm/dd/yyyy)
ate Case Received (mm/dd/yyyy)
For OCSE PSOC Use
STATE REFERRAL: FEDERAL CRIMINAL PROSECUTION
FOR NON-SUPPORT (18 U.S.C. §228)
Project Save Our Children
State of
*
_____ County of ____
For OCSE PSOC Use
IV-D Case Number
*
_________
P
SOC Case Number
SECTION 1 – PAYER INFORMATION
Name of
Payer*
Social Security
Number*
Date of
Birth*
(mm/dd/yyyy)
Last
First
Middle
Place of Birth
Last Known Address (Street Name and Number)
Telephone Number(s)
City
State & Zip Code
Was the address verified?
If so, when (mm/dd/yyyy)
Employer Name
Employer Address
Telephone Number
Wage and Income
History*
Date
Verified*
(mm/dd/yyyy)
Source of
Verification*
Occupation
Professional License
Auto & Driver’s License / State Issued
Alias
Does the Payer have any current warrants? If yes, please indicate type and where issued.
Brief Physical Description (Race, sex, height, weight, eyes, hair color, tattoo etc.)
SECTION 2 – ORDER INFORMATION
Date Order was
Entered*
Amount Ordered
When Was the Last Payment?
Arrearage*
Arrears from Date (mm/dd/yyyy) Arrears to Date (mm/dd/yyyy)
ATTACH PAYMENT HISTORY & ORDER
Attach any locate or additional information that would assist in processing the case.
330 C Street, SW, 5th Floor, Washington DC 20201 |

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