State Referral: Federal Criminal Prosecution For Non-Support Form - Project Save Our Children - Office Of Child Support Enforcement Page 2

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STATE REFERRAL FEDERAL CRIMINAL PROSECUTION
FOR NON-SUPPORT (18 U.S.C. §228)
SECTION 3 – REFERRAL
INFORMATION* (This section must be filled out completely.)
State
County
Name of Referring Agency
Referral Date (mm/dd/yyyy)
State Contact Person
Direct Phone Number
FAX
Address of Referring Agency (Street Name and Number)
Email Address
City
State
Zip Code
SECTION 4 – CUSTODIAL PARTY INFORMATION
Name of Custodial
Party*
Social Security
Number*
Date of
Birth*
(mm/dd/yyyy)
Last
First
Middle
Place of Birth
Street Name and
Number*
City*
State*
Zip
Code*
Home Phone Number
Business Phone Number
Spouse’s Phone Number
Does custodial party have any restraining/protective orders against payer?
No
Yes
Has this party signed a non-disclosure form?
No
Yes
SECTION 5 – CHILD INFORMATION
Place of Birth
State of Residency
Name of Child
*
Date of
Birth*
(mm/dd/yyyy)
Last
First
Place of Birth
State of Residency
Name of Child
*
Date of
Birth*
(mm/dd/yyyy)
Last
First
Place of Birth
State of Residency
Name of Child
*
Date of
Birth*
(mm/dd/yyyy)
Last
First
SECTION 6 – PROSECUTOR
REVIEW* (This section must be filled out completely.)
Has this case been reviewed by a prosecutor for possible state criminal
If yes, by whom? (List prosecutor’s or assistant’s name and phone
charges?
number.)
No
Yes
If yes, what was the outcome of the review? (criminal warrant, case did not meet an element of state law, etc.)
3
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