Application For Child Support Enforcement Services Page 3
ADVERTISEMENT
1
2
3
4Height : __________ Weight: ________ Hair Color: ____________ Eye Color: ___________
Give any distinguishing features or marks that would help identify (tattoo, scar, piercing, birthmark, physical
impairment, etc.) _________________________________________________________________________
Provide the names of family members or friends who may be able to assist in locating the non-custodial parent:
_______________________________________________________________________________________
_______________________________________________________________________________________
Mothers Full Legal Name: ______________________________________ SSN: ____________________
Maiden Name: _______________________Date of Birth:_____________ Birthplace: _________________
Enrolled Tribal Member Y N
Other Tribe: __________________________Non-Native:
Y N
Home Phone: _________________Cell Phone: __________________ Work Phone:___________________
Physical Address: ________________________________________________________________________
City
State
Zip
Mailing Address if different: _______________________________________________________________
City
State
Zip
Is this address on a reservation?
Yes
No Reservation Name ___________________
Height : __________ Weight: ________ Hair Color: ____________ Eye Color: ___________
Give any distinguishing features or marks that would help identify (tattoo, scar, piercing, birthmark, physical
impairment, etc.) _________________________________________________________________________
Provide the names of family members or friends who may be able to assist in locating the non-custodial parent:
_______________________________________________________________________________________
_______________________________________________________________________________________
III. CHILDREN INFORMATION
NAME
SEX
DOB
SSN
E
PATERNITY
NROLLED
Tribe
Established
_______________________ M F
_________
________________ Y N ____________
Y N
_______________________ M F
_________
________________ Y N ____________
Y N
_______________________ M F
_________
________________ Y N ____________
Y N
_______________________ M F
_________
________________ Y N ____________
Y N
IV. NON-CUSTODIAL PARENT FINANCIAL INFORMATION
Is the Non-Custodial Parent currently working?
Yes
No
If Yes, is the employer either the Tribe or a tribally-owned business?
Yes
No
Employer Name: __________________________________________
Employer Address; ____________________________________________________________
Street/City/State/Zip Code
Employer Phone Number: __________________
Hourly Pay $ __________ Hours Per Week ______ If salaried, salary per year______________
Is health insurance available through work?
Yes
No
List Other Sources of Income:
Source: _________________________ Amount received $____________ Frequency ________
Source: _________________________ Amount received $____________ Frequency ________
Source: _________________________ Amount received $____________ Frequency ________
ADVERTISEMENT
0 votes
