Kansas Payment Center - Child Support Order Information Sheet (Page 2 of 2) in pdf

Kansas Payment Center - Child Support Order Information Sheet Page 2

Information about the Parent or Person RECEIVING support

NAME (First, Middle Initial, Last): _________________________________________________________________

Address: ____________________________City: ____________________________State: __________ Zip: ______

Social Security Number: _______________ Date of Birth:____________

Phone Number: _________________

Information about the Third Party Payee

NAME (First, Middle Initial, Last): _________________________________________________________________

Address: ____________________________City: ____________________________State: __________ Zip: ______

Social Security Number: _______________ Date of Birth:____________

Phone Number: _________________

Information about CHILD(REN) covered by this support order

NAME (First and Last:

Social Security Number

Date of Birth

1. _________________________

___________________

2. _________________________

___________________

3. _________________________

___________________

4. _________________________

___________________

5. _________________________

___________________

6. _________________________

___________________

7. _________________________

___________________

8. _________________________

___________________

Form completed by: _______________________________________________ Date: ________________________

Print Name (and title): __________________________________________________________________________

The completed form must be attached to the journal entry and filed with the Clerk of the District Court.

Kansas Payment Center - Child Support Order Information Sheet Page 2