TANF ( ) MEDICAID ( ) NADC ( ) ELKHART COUNTY CHILD SUPPORT APPLICATION (PLEASE PRINT) CUSTODIAL PARENT’S NAME______________________________________________________ (Last First Middle ) DATE OF BIRTH ___________________ SOCIAL SECURITY #_______________________________ (Month/Day/Year) SEX ___________ RACE:_______________ PLACE OF BIRTH__________________________ (City/County/State) ADDRESS ___________________________________________________________________________ ( Number and Street City State ZIP Code ) MAILING ADDRESS IF DIFFERENT ____________________________________________________ (Number and Street City State ZIP Code) TELEPHONE NUMBER _____________________________/__________________________________ ( Area Code/Home /Area Code/ Work ) THE NAME OF A PERSON THAT WOULD ALWAYS KNOW YOUR WHEREABOUTS ______________________________________________ ______________________________________ Name Telephone Number ___________________________________________________________ _________________________ Address Relationship HAVE YOU EVER RECEIVED A TANF/AFDC WELFARE CHECK IN INDIANA __ YES __NO IF YES GIVE THE MONTH AND YEAR OF THE LAST CHECK___________________________ THE COUNTY YOUR CASE WAS ACTIVE _____________________________________________ DEPENDENT DATA-I WISH TO SECURE CHILD SUPPORT PAYMENTS ON BEHALF OF THE FOLLOWING CHILD(REN): CHILD’S FULL NAME (LAST, FIRST, MIDDLE) SEX DATE OF BIRTH PLACE OF BIRTH SS# ( MO, DAY,YEAR) (CITY/STATE) RELATIONSHIP TO YOU American LegalNet, Inc. www.USCourtForms.com NON-CUSTODIAL PARENT’S NAME__________________________________________________ (Last First Middle) ALIAS OR NICKNAME:_________________________________________________________________ SOCIAL SECURITY NUMBER ___________________ DATE OF BIRTH ___________ AGE _______ PLACE OF BIRTH ______________________________ RACE ______ HEIGHT ____ WEIGHT ______ (CITY COUNTY STATE) HAIR COLOR ________ EYE COLOR ________ ADDRESS: ___________________________________________________________________________ (NUMBER STREET APT. # CITY STATE ZIP CODE) CURRENT ADDRESS/____ YES _____ NO / LAST KNOWN ADDRESS/________________________ (HOW MANY YEARS AGO) EMPLOYER: CURRENT___LAST KNOWN___ (HOW MANY YEARS AGO) _________________ EMPLOYER’S ADDRESS _______________________________________________________________ (Number Street City State ZIP Code ) Marital Status of Parties: __ Married __ Deserted __ Divorced __ Never Married __ Separated __ Unknown Date Married_________ Location of Wedding____________ Date Separated or Divorced ___________________________ City /County/State of Divorce _________________________ __________________________________________________ Complete if Non Custodial Parent __ Is currently __ Or has been in the military service Branch of Service ___ Army ___ Navy ___ Marines___ Air Force ___ Coast Guard Non Custodial Parent’s Arrest Record ___ yes ___ no If yes, where was absent parent last arrested? (City County State Date ) Is Non Custodial Parent Currently in a jail, prison or institution? ___ yes ___ no (City County State ) Non Custodial parent’s father’s name and address______________________________________________ Non Custodial parent’s mother’s name and address_____________________________________________ Non Custodial parent’s mother’s maiden name_________________________________________________ Is Non Custodial parent currently married , if so name of new spouse ______________________________ Does non custodial parent have any other child(ren), if so full names of child(ren) and their custodial parent name. American LegalNet, Inc. www.USCourtForms.com COMPLETE THIS SECTION IF CHILD IS BORN OUT OF WEDLOCK Has paternity been filed with a Court? ___ yes ____no Date ___________ Place________________________ (City County State) Has paternity been established by a Court? ___ yes ___ no Date ___________ Place _______________________ (City County State) COURT DATA Has non custodial parent ever been ordered by a court to pay support for your children: __ yes ___ no Name and Address of Court _______________________________________________________________ If no, has a petition been filed and a hearing pending in a Court? ___ yes ___ no Name and Address of Court _______________________________________________________________ Cause Number of Court Order _____________________________________________________________ Amount of Support Ordered $ ______ per week/month Is non custodial parent paying support? ___yes ___ no To Whom Does Non Custodial Parent pay support: __ Clerk ___ Directly to you Date last paid ______ Is Non Custodial Parent paying by military allotment? ___ yes ___no Amount ________ per wk/month ASSIGNMENT FOR COLLECTION OF CHILD SUPPORT NAME OF NON CUSTODIAL PARENT ____________________________________________________ NAME(S) OF CHILD(REN) I understand and agree that support payments collected hereafter from the non custodial parent named above on behalf of myself and or the above named child(ren) will be paid to the Indiana Child Support Bureau, a Division of the Indiana Family and Social Services Adminstration, and that said support payments will be paid to me by the agency after deduction of any charges due and owing to that Agency. Such charges are explained on page one of the “Application for Title IV-D Child Support Services “ executed by the applicant. This authorization shall continue in effect until terminated in the manner set forth on page one of the “Application for Child Support Services”. Printed Name of Applicant Signature of Applicant Court Cause Number Date Court Name American LegalNet, Inc. www.USCourtForms.com