Child Support Case Registry Form Page 2
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4PETITIONER/PLAINTIFF:
CASE NUMBER:
RESPONDENT/DEFENDANT:
OTHER PARENT:
The child support order is for the following children:
4.
Child’s name
Date of birth
Social security number
a.
b.
c.
Additional children are listed on a page attached to this document.
You are required to complete the following information about yourself. You are not required to provide information about the other
person, but you are encouraged to provide as much as you can. This form is confidential and will not be filed in the court file. It will be
maintained in a confidential file with the State of California.
5.
Father’s name:
Mother’s name:
6.
a.
Date of birth:
a.
Date of birth:
b.
Social security number:
b.
Social security number:
c.
Street address:
c.
Street address:
City, state, zip code:
City, state, zip code:
d.
Mailing address:
d.
Mailing address:
City, state, zip code:
City, state, zip code:
e.
Driver’s license number:
e.
Driver’s license number:
State:
State:
f.
Telephone number:
f.
Telephone number:
g.
Employed
Not employed
Self-employed
g.
Employed
Not employed
Self-employed
Employer’s name:
Employer’s name:
Street address:
Street address:
City, state, zip code:
City, state, zip code:
Telephone number:
Telephone number:
7.
A restraining order, protective order, or nondisclosure order due to domestic violence is in effect.
a.
The order protects:
Father
Mother
Children
b.
From:
Father
Mother
c.
The restraining order expires on (date):
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:
(TYPE OR PRINT NAME)
(SIGNATURE OF PERSON COMPLETING THIS FORM)
Page 2 of 4
CHILD SUPPORT CASE REGISTRY FORM
FL-191 [Rev. July 1, 2005]
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