Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
UIFSA Questionnaire Form. This is a Indiana form and can be use in Elkhart Local County.
Loading PDF...
Tags: UIFSA Questionnaire, Indiana Local County, Elkhart
UIFSA QUESTIONNAIRE
IN ORDER TO FILE A UIFSA PETITION, WE MUST HAVE THE FOLLOWING
INFORMATION. THESE QUESTIONS MUST BE ANSWERED FULLY AND COMPLETELY.
IF YOU ARE UNABLE TO ANSWER A SPECIFIC QUESTION, YOU MUST STATE WHY
THAT QUESTION CANNOT BE ANSWERED. THIS INFORMATION WILL BE USED FOR
PURPOSES OF THE UIFSA ACTION ONLY.
DATE:
INFORMATION ABOUT YOURSELF:
YOU R NAME AND ADDRESS (Including City and State)
S.S.#
DATE OF BIRTH:
PHYSICAL DESCRIPTION: HEIGHT:
HAIR:
EYES:
AGE:
WEIGHT:
RACE:
HM. PHONE:
WK. PHONE:
OCCUPATION:
RELATIONSHIP TO CHILD(REN):
CURRENT MARRITAL STATUS:
RELATIONSHIP TO ABSENT PARENT:
IF YOU ARE NOT THE NATURAL MOTHER OR FATHER OF THE CHILD(REN) GIVE THE
NAME(S) AND ADDRESS OF THE NATURAL PARENT(S):
LIST ALL PERSONS LIVING IN YOUR HOUSEHOLD:
NAME:
DOB:
RELATIONSHIP:
SOURCE OF INCOME:
American LegalNet, Inc.
www.USCourtForms.com
INFORMATION ABOUT THE NON-CUSTODIAL PARENT:
NAME AND ADDRESS (Including City and State):
MAIDEN, ALIAS OR NICK NAME:
ATTACH PHOTO:
PLACE OF BIRTH:
AGE:
D.O.B.:
RACE:
S.S.#
HEIGHT:
WEIGHT:
SCARS:
HAIR:
EYES:
TATOOS:
WK. PHONE:
HM. PHONE:
EMPLOYERS NAME AND ADDRESS:
OCCUPATION, TRADE OR PROFESSION:
ESTIMATE GROSS MONTHLY INCOME:
OTHER INCOME:
REAL OR PERSONAL PROPERTY:
PRESENT MARITAL STATUS (IF KNOWN):
CURRENT SPOUSE/PARTNER EMPLOYED?:
ESTIMATED GROSS MONTHLY EARNINGS:
NAME AND ADDRESS OF CURRENT SPOUSE/PARTNER’S EMPLOYER:
IS THE NON-CUSTODIAL PARENT RESPONSIBLE FOR DEPENDENTS THAT ARE NOT
LIVING IN YOUR HOUSEHOLD?
NAME:
D.O.B.
RELATIONSHIP
LIVING WITH
American LegalNet, Inc.
www.USCourtForms.com
INFORMATION ABOUT THE CHILD(REN): LIST CHILD(REN) OF NON-CUSTODIAL
PARENT ONLY.
NAME:
AGE:
SEX:
D.O.B.
S.S.#
PATERNITY ESTABLISHED
[ ] YES
[ ] NO
SUPPORT ORDER
[ ] YES
[ ] NO
LIVING WITH PETITIONER
[ ] YES
[ ] NO
INFORMATION ABOUT MARITAL STATUS:
WERE YOU MARRIED TO THE NON-CUSTODIAL PARENT?
IF SO, DATE:
STATE, CITY, COUNTRY:
DATE DIVORCE FINALIZED:
ARE YOU NOW DIVORCED?
NAME AND ADDRESS OF COURT:
AMOUNT OF SUPPORT:
DATE OF COURT ORDER:
WAS PATERNITY ESTABLISHED:
IN WHICH STATE WAS PATERNITY ESTABLISHED:
HOW MANY TIMES HAVE YOU BEEN MARRIED:
NAME:
DATE:
LOCATION:
American LegalNet, Inc.
www.USCourtForms.com
NAME OF SPOUSE/PARTNER:
YOUR GROSS WEEKLY INCOME:
MEDICAL INSURANCE:
ARE THE DEPENDENTS FOR WHOME SUPPORT IS SOUGHT PRESENTLY COVERED BY
MEDICAL INSURANCE:
IS THE NON-CUSTODIAL PARENT ORDERED TO PROVIDE MEDICAL INSURANCE:
WHO PROVIDES MEDICAL INSURANCE FOR THE CHILD(REN) AT THIS TIME:
THE NAME OF THE INSURANCE COMPANY:
POLICY NUMBER:
INSURANCE COMPANY OF CUSTODIAN’S EMPLOYER:
COST PER MONTH:
WERE THE CHILDREN EVER COVERED BY MEDICAL INSURANCE PROVIDED BY THE
NON-CUSTODIAL’S EMPLOYER?
DO ANY OF THE NON-CUSTODIAL’S CHILDREN HAVE SPECIAL NEEDS OR
EXTRAORDINARY MEDICAL EXPENSES NOT COVERED BY INSURANCE?
IF SO, PLEASE EXPLAIN:
CRIMINAL INFORMATION:
DOES THE NON-CUSTODIAL PARENT HAVE A TRAFFIC OR CRIMINAL RECORD:
VIOLATION:
DATE:
LOCATION:
INCARCERATED:
SUPPORT ORDER AND PAYMENT INFORMATION:
IS THE ABSENT PARENT PAYING CURRENT CHILD SUPPORT:
AMOUNT OF THE ORDER:
WHEN DID THE RESPONDENT MAKE THE LAST SUPPORT/ARREARAGE PAYMENT
AND HOW MUCH WAS THE PAYMENT?
HAS THE RESPONDENT EVER PAID CHILD SUPPORT DIRECTLY TO YOU?
IF SO, HOW MUCH, AND THE DATE PAYMENTS WERE MADE:
DO YOU HAVE RECEIPTS FOR ANY PAYMENTS MADE DIRECTLY TO YOU?
IF YES, PLEASE ATTACH.
American LegalNet, Inc.
www.USCourtForms.com
FINANCIAL INFORMATION:
EMPLOYED: [ ] YES
[ ] NO
IF YES, PLEASE LIST OCCUPATION:
PUBLIC ASSISTANCE:
AMOUNT:
MONTHLY AFDC PAYMENTS
MONTHLY FOOD STAMP BENEFITS
OTHER:
EMPLOYMENT INCOME:
[ ] GROSS [ ] NET
(ATTACH 3 OF YOUR MOST RECENT PAY STUBS FROM EACH CURRENT EMPLOYER)
DEDUCTIONS:
INCOME TAX WITHHOLDING (FEDERAL + STATE + LOCAL)
FICA (SOCIAL SECURITY)
MANDATORY UNION DUES
MANDATORY RETIREMENT
MEDICAL INSURANCE PREMIUMS COVERAGE
THE DEPENDENTS
OTHER:
OTHER EARNINGS:
MONTHLY BUSINESS INCOME
EXPLAIN:
MONTHLY EXPENSES:
CHILD CARE:
PROVIDER:
FREQUENCY:
UNINSURED EXTRAORDINARY MEDICAL (ATTACH DESCRIPTION & DOCUMENTATION)
OTHER SUPPORT PAYMENTS, ACTUALLY MADE
EDUCATION (RESPONDENT’S CHILDREN)
HOUSING AND UTILITIES
FOOD & HOUSEHOLD SUPPLIES
OTHER EARNINGS:
MONTHLY CHILD SUPPORT:
MONTHLY ALIMONY OR SPOUSAL SUPPORT INCOME:
GOVERNMENT PAYMENTS:
EXPLAIN:
MONTHLY PENSION BENEFITS:
SOURCE:
UNEMPLOYMENT COMPENSATION:
SOURCE AND DURATION:
American LegalNet, Inc.
www.USCourtForms.com
OTHER MONTHLY INCOME:
SOURCE AND EXPLAIN:
DEPENDENT’S INCOME:
[ ] GROSS [ ] NET
(ATTACH THE THREE MOST RECENT STUBS FROM EACH CURRENT EMPLOYER)
PROVIDE ANY ADDITIONAL INFORMATION IMPACTING INCOME, PARTICIPATION IN
JOBS PROGRAM
MONTHLY EXPENSES (CONTINUED)
TRANSPORTATION:
PERSONAL EDUCATION EXPENSES:
OTHER UNINSURED HEALTH RELATED EXPENSES:
CLOTHING:
INSURANCE PREMIUMS:
ENTERTAINMENT:
ALL OTHER EXPENSES AND PAYMENTS:
American LegalNet, Inc.
www.USCourtForms.com
