CIRCUIT COURT OF JACKSON COUNTY, MISSOURI INFORMATION STATEMENT TO THE DEPARTMENT OF JUDICIAL RECORDS FOR PROCESSING OF MAINTENANCE AND SUPPORT PAYMENTS DATE OF DECREE/ORDER MONTH DAY YEAR DATE CASE NO. CASE TYPE PAYABLE TO AGENCY: ( ) NAME OF AGENCY 1. NAME (LAST) (FIRST) (M.I.) (T) 2. SOCIAL SEC NO 3. BIRTH DATE (MONTH) (DAY) (YEAR) 4. ADDRESS (STREET) (CITY) (STATE) (ZIP) 5. HOME PHONE 6. EMPLOYER (COMPANY NAME) 7. EMPLOYERS ADDRESS (STREET) (CITY) (STATE) (ZIP) 8. EMPLOYERS PHONE 9. ARE YOU NOW RECEIVING AFDC?
YES
NO IF YES, CASE NO. ________________________________________________________ 10. ARE YOU NOW RECEIVING SERVICES FROM A IV-D AGENCY?
YES
NO IF YES, IV-D CASE NO. ____________________________________________________ 11. RELATED CASE NUMBER __________________________________________________________________ 1. NAME (LAST) (FIRST) (M.I.) (T) 2. SOCIAL SEC NO 3. BIRTH DATE (MONTH) (DAY) (YEAR) 4. ADDRESS (STREET) (CITY) (STATE) (ZIP) 5. HOME PHONE 6. WAS IMME DIATE INCOME WITHHOLDING ORDERED?
YES
NO 7. EMPLOYER (COMPANY NAME) 8. EMPLOYERS PHONE 9. EMPLOYERS ADDRESS (STREET) (CITY) (STATE) (ZIP) THE ABOVE INFORMATION IS REQUIRED TO MAINTAIN PROPER RECORDS, PURSUANT TO LOCAL RULE 100.5.1.1, IN ANY ACTION IN WHICH THE COURT ENTERS AN ORDER THAT MAINTENANCE OR SUPPORT BE MADE TO THE COURT ADMINISTRATOR AS TRUSTEE, THE ATTORNEY OR PARTY OBTAINING SUCH ORDER SHALL PREPARE AND FILE INFORMATION STATEMENT FORM CIRCT 1408, WITH THE COURT ADMINISTRATORS OFFICE. A TRUST WILL BE ESTABLISHED AT THE TIME THE ORDER IS ENTERED, HOWEVER, PAYMENTS WILL NOT BE MAILED TO THE PAYEE WITHOUT THE FILING OF THIS FORM. I CERTIFY THE ABOVE INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE. _________________________________________________________________ SIGNATURE OF PAYEE OR ATTORNEY FOR PAYEE NAME OF ATTORNEY NAME OF FIRM P HONE TOTAL MONTH OR WEEK MONTH DAY YEAR JUDGMENT $ PER FIRST PAYMENT DUE MONTH OR WEEK *STATE DEBT $ PER INITIAL LETTERS JUDGMENT RENDERED IN KANSAS CITY INDEPENDENCE COUPONS CIRCT 1408 - 3/94 *INFORMATION TO BE COMPLETED FOR IV-D CASES ONLY. PAGE 1 OF 2 >>>> 2 1. NAME (LAST) (FIRST) (M.I.) (T)IRTHDATB E SOCIAL SECURITY NUMBER (MO) (DAY) (YR) (1) (1) (1) (2) (2) (2) (3) (3) (3) (4) (4) (4) CHECK IF MORE THAN FOUR CHILDREN THEN CONTINUE BELOW EFFECTIVE DATE AMOUNT FREQUENCY TYPE OF CASE CIRCT 1408 - 3/94 PAGE 2 OF 2