State Referral: Federal Criminal Prosecution For Non-Support Form - Project Save Our Children - Office Of Child Support Enforcement Page 6

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STATE REFERRAL FEDERAL CRIMINAL PROSECUTION
FOR NON-SUPPORT (18 U.S.C. §228)
SECTION 4 – CUSTODIAL INFORMATION
Name of Custodial Party:
*
Enter last name, first name and middle initial of the custodial party.
Social Security
Number:*
Enter the SSN of the custodial party. Format 000-00-0000.
Date of Birth:
*
Enter the date of birth for the custodial party. Format MM/DD/YYYY.
Place of Birth:
(Not required.) Enter the place of birth (city/state) for the custodial party if
known.
Street Name and
Number:*
Enter the street number and name of the mailing address of the custodial
party
City:*
Enter the city where the custodial party resides.
State:*
Enter the state abbreviation of where the custodial party resides.
Zip
Code:*
Enter the mailing zip code of the custodial party.
Home Phone Number:
Enter the home phone number of the custodial party.
Business Phone Number:
Enter the business phone number of the custodial party if it applies.
Spouse’s Phone Number:
Enter a phone number that can be used to reach the spouse of the custodial
party if it applies.
Does custodial party have any restraining
Check the appropriate box with an “X” if there are any orders of protection
orders against the payer?
*
against the payer for the custodial party.
Has this party signed a non-disclosure
Check the appropriate box with an “X.”
form?
SECTION 5 – CHILD INFORMATION
Name of Child: *
Enter the name of the child starting with the last name first then the first
name.
Date of Birth: *
Enter the birth date of the child. Format MM/DD/YYYY.
Place of Birth:
Enter the city and state the child was born in.
State of Residency:
Enter the state where the child has residency.
If there is more than one child involved, continue to enter the remaining children’s’ information in the blocks provided. If there
are more than three children, enter the remaining children in the space provided in Section VII.
SECTION 6 – PROSECUTOR REVIEW
* (This section must be filled out completely.)
Has this case been reviewed by a
Check the appropriate box with a “X” if a state or federal prosecutor has
prosecutor for possible state criminal
reviewed the case
charges?
If yes, by whom?:
Enter the name of the prosecutor that reviewed the case with the
jurisdiction where that prosecutor has jurisdiction. (Example: John Doe,
Fulton County DA’s Office).
If yes, what was the outcome?
If a prosecutor has looked at the case and indicated that the case could not
be prosecuted at the state level or the federal level, please describe the
reason here.
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