LICKING COUNTY CHILD SUPPORT ENFORCEMENT AGENCY INFORMATION FORM RESIDENTIAL PARENT 1. 2. 3. 4. 5. Name: First Middle Last Maiden Other Names Used: Birth Date: Social Security Number: Address: Street City State Zip Birthplace: Marital Status: Mailing Address: Previous Address: Address verified? (Agency Use Only) Yes No How? , Message , Contact Person Phone Number: Home 6. Your Current or Most Recent Employer: Full Address: Number and Street City State Suite Zip Phone Type of Business: Date Started Job: Gross Pay Per Month: $ Insurance Coverage: Access to Private Medical Insurance? Residential Parent's Position: If no longer employed, date left job: Union Name: Insurance Company: Licking County Child Support Enforcement Agency 65 East Main Street P.O. Box 338 Newark, Ohio 43055-0338 (740)349-6575 or 1-800-513-1128 American LegalNet, Inc. www.USCourtForms.com 7. Residential Parent's Family: Father: Address: Mother: Married Name / Maiden Name Telephone Number: Telephone Number: Address: Other Message Phone: Relationship: CHILD 1. 2. 3. 4. Name: First Middle Last Male Birth Date: Residence: Female Race: Birth Place: SSN: Street City State Zip Address Verified? (Agency Use Only) Yes No No How? Child's relationship to caretaker: Yes Yes No No Yes No Is child deemed disabled? Yes No 5. 6. 7. Born out of wedlock? Yes Is child covered by medical insurance? Is there a support order for this child? Is child living with an Ohio Welfare Family recipient? 2 American LegalNet, Inc. www.USCourtForms.com NON-RESIDENTIAL PARENT 1. 2. 3. Name: First Middle Last Maiden Other Names Used: Address (Current or Last Known (Circle)): Street City State Zip Address Verified? 4. 5. 6. 7. Birth Date: Yes No How? Birthplace: Social Security Number: Phone Number: Last Known Employer for Non-Residential Parent (Does he/she still work there?) Employer's Name: Full Address: Street City State Zip Phone: Type of Business: Date Started Job: Gross Pay Per Month: $ Insurance Coverage: Access to Private Medical Insurance? Who paid birthing expenses: 8. Fax: Non-Residential Parent's Position: If no longer employed, date left job: Union Name: Insurance Company: Insurance / Self / State of Ohio / Other: What other source(s) of income does the Non-Residential Parent have? (give amount) Unemployment Benefits: Worker's Comp Benefits: Disability Benefits: Other (Explain): $ $ $ Social Security Benefits: Veteran Benefits: Retirement Benefits: $ $ $ $ 3 American LegalNet, Inc. www.USCourtForms.com 9. What assets does the Non-Residential Parent have? (Describe) Bank Accounts: Motor Vehicles: Make Model Year Lic plate State Real Property: Other (Explain): 10. Description of Non-Residential Parent: Male Female Race Height Weight Scars Birthmarks Hair Tattoos? ; Beard Mustache, any other distinguishing features? Eyes Does the Non-Residential Parent have: (Circle) If so, describe: Glasses 11. Non-Residential Parent's Level of Education: High School Attended: _________________________________ University or Technical School Attended: Degrees: Graduated? Yes No 12. Licenses? Drivers: Motorcycle: Chauffeurs: Professional: ___________________ What State: 13. Arrest Record? Date: Incarceration? Date: Probation / Parole? Probation/Parole Officer: Address: 14. Military Service: Dates (Circle One) Army Navy Air Force to Marines Honorable / Dishonorable Discharge Reserves National Guard Where: Where: Where? Charge: Charge: Dates: Phone: Gross Amount: $ Contact Phone Number: 4 American LegalNet, Inc. www.USCourtForms.com 15. Non-Residential Parent's Family: Father: Address: Mother: Married Name / Maiden Name Telephone Number: Telephone Number: Address: Is the Non-Residential Parent a minor? If Yes, with whom do they reside? Brother / Sister / Friend (Circle One): Address: 16. Telephone Number: Marital Status Spouse/Friend Yes No Non-Residential Parent's Current: Spouse / Girlfriend / Boyfriend (Circle One): Name: Address: Any Children in the Home: Ordered to pay child support to anyone else? What County, State? How Many? To Whom? Telephone Number: 17. Are you currently residing with the Non-Residential Parent? If No, last address you shared: Yes No Date: Phone or Person? 18. 19. Last date of contact with Non-Residential Parent: Additional Comments: 5 American LegalNet, Inc. www.USCourtForms.com IF YOU AND THE NON-RESIDENTIAL PARENT WERE MARRIED WHEN THE CHILD WAS BORN: 1. Date you were married: Date you were separated: Have either of you filed for: Legal Separation: Date: 2. County and State: Dissolution: Divorce: County and State: Docket No. Yes No Has the Non-Residential Parent been Court ordered to pay child support? Date: Docket No. County and State: Support Amount Ordered: $ Yes Yes No No per Has there been any change in the initial Court Order? Are these payments taken directly from wages? Was the Non-Residential Parent ordered to pay through the Child Support Enforcement Agency? Yes No When was the last time support was paid? 3. 4. Is this case: Interstate Only Locate Only Support Only Medical Support Only Have you ever received public assistance in Licking County? If so, in what name? 5. 6. Is Good Cause claimed? Additional Comments: Is this a confidential case? 6M American LegalNet, Inc. www.USCourtForms.com IF YOU AND THE NON-RESIDENTIAL PARENT WERE NOT MARRIED WHEN THE CHILD WAS BORN: 1. Has paternity been established? County and State: Yes No Date: Docket No. If not, is the Putative Father willing to cooperate in establishing paternity through the court? Yes No Did the alleged Putative Father sign the birth certificate? Method of establishment: Conception date: 2. Yes No Yes No Filed with Central Paternity Registry? State: City: Yes Has the Non-Residential Parent been Court ordered to pay child support? Date: Docket No. County and State: Support Amount Ordered: $ Yes Yes No No per No Has there been any change in the initial Court Order? Are these payments taken directly from wages? Was the Non-Residential Parent ordered to pay through the Child Support Enforcement Agency? Yes No When was the last time support was paid? 3. 4. Is this case: Interstate Only Locate Only Support Only Medical Support Only Have you ever received public assistance in Licking County? If so, in what name? 5. 6. Is Good Cause claimed? Additional Comments: Is this a confidential case? 6P American LegalNet, Inc. www.USCourtForms.com ACKNOWLEDGMENTS Initials I UNDERSTAND CSEA FILES AND PAYMENT INFORMATION ARE CONFIDENTIAL AND IF I WISH TO DESIGNATE AN AU