CS-ES52 INet R. 9/07 #: Child Support Enforcement ADDITIONAL PARENT INFORMATION To be completed by CSE NA PA Applicant is: Custodial Parent 1. Information about you Does the child live with you? You are the child’s: PLEASE PRINT Yes mother Noncustodial Parent No If no, who do they live with? father grandparent legal guardian If you are not the parent, Mother give the names of the children’s parents: Name (First, Middle, Last): other, specify _______________________________ Father How long have the child(ren) lived with you? Social Security Number: Race Sex Mailing Address: Date of Birth: City: Home Phone (include area code): Best time to call: State/Zip Code: Work Phone (include area code): Best time to call: Was the mother married when the child was born? Where (City/State)? ___________________ Divorced? Yes No If yes, to whom? Yes When? __________________ Yes Yes No No A separate form is required for each parent not living in your home Name (First, Middle, Last): Home Phone (include area code): Current Address: Work Phone (include area code): Last Known Mailing Residential (check all that apply) Dates other parent lived with you and the child(ren) From: ___________ To: ______ _____ Where? (City/State):_________________________________ Employer: City: State/Zip Code: Social Security Number: Date of Birth: Employer’s Address: Place of Birth: Race: _______________________ No If yes, Date: ____________ Any other legal action pending?: I have a fear of family violence and want my location kept confidential: 2. Information about the other parent Other Legal Names Used: Employer’s City: Sex: Weight: Height: Hair: Eyes: Employer’s State/Zip Code: Other Identifying Features: 3. Child(ren) Who Need Services Child’s Name/sex Social Security Number Child #1 __________________________ M F Child #2 __________________________ M F Child #3: __________________________ M F __ __ __ -__ __ -__ __ __ __ __ __ __ -__ __ -__ __ __ __ __ __ __ -__ __ -__ __ __ __ ______/______/______ ______/______/______ ______/______/______ Place of Conception (City/State) Place of Birth (City/State) Date of Birth (MM/DD/YY) Were the parents married Yes No Yes No Yes No when the child was born? Did the father sign the birth Yes No Yes No Yes No certificate? If other possible fathers, list name(s) and complete another form: Is there a support order for Yes No Medical Only Yes No Medical Only Yes No Medical Only this child? Covered by other parent’s Yes No Yes No Yes No medical insurance? Please include copies of any paternity, divorce, or child support orders you have for the child(ren). If there are orders but you do not have copies, please give us the information so we can get them. County and state where order was entered: Approximate date: Case number, if known: Please check one of the boxes below to show where the other parent is ordered to make child support payments: Child support payments are made to the Clerk of Court Child support payments are paid directly to me If you need help, call Customer Contact Center at 1-800-622-5437 or go to http://www.myflorida.com/dor/childsupport Your Social Security number and the child(ren)’s are required by section 409.2567, Florida Statutes and Rule 12E-1.003(2)(a), Florida Administrative Code. We will use the numbers only for purposes directly connected with child support enforcement. American LegalNet, Inc. www.FormsWorkflow.com