State Referral For Federal Criminal Prosecution Page 2
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1
2
3SECTION III – REFERRAL INFORMATION
Name of Referring Agency
Referral Date
State
County
Mon
Day
Yr
State Contact Person
Direct Phone Number
FAX
-
-
-
-
Address of Referring Agency (Street Name and Number)
E-Mail Address
City
State
Zip Code
SECTION IV – CUSTODIAL PARTY INFORMATION
Custodial Party Name
Social Security Number
Date of Birth
Last
First
MI
Month
Day
Yr
-
-
Place of Birth_
_
Street Name and Number (last known address)
City
State
Zip Code
Home/Cell Phone
Business Phone
Spouse Number
-
-
-
-
-
-
Does Custodial Parent Have any Restraining/Protective Orders Against Payer?
No
Yes
Has this Parent Signed a Non-Disclosure Form?
No
Yes
SECTION V – CHILD INFORMATION
Name of Child
Date of Birth
Place of Birth
State of Residency
Last
First
Month
Day
Yr
Name of Child
Date of Birth
Place of Birth
State of Residency
Last
First
Month
Day
Yr
Name of Child
Date of Birth
Place of Birth
State of Residency
Last
First
Month
Day
Yr
SECTION VI – PROSECUTOR REVIEW
Has This Case Been Reviewed By a Prosecutor for Possible State Criminal
If Yes, By Whom? (List prosecutor and/or assistant’s name and phone
Charges?
number)
-
-
No
Yes
What Was the Outcome of the Review? (e.g., was a criminal warrant issued, did case not meet an element of state law, etc.)
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