CHILD SUPPORT CASE INFORMATION SECTION I - APPLICANT CHILD SUPPORT INFORMATION APPLICANT INFORMATION - Please complete this information about yourself Your relationship to the child(ren): Mother Father Aunt Uncle Paternal Grandparent Maternal Grandparent Guardian Other Does the child(ren) live with you? Yes If no, who does the child(ren) live with? Name: Address: City: State: Are you currently receiving Public Assistance? Did you ever receive Public Assistance? Did you ever receive Medicaid? No Zip Code: Yes Yes Yes No No No APPLICANT INFORMATION REGARDING CURRENT AND/OR PAST CHILD SUPPORT ARRANGEMENTS Please provide all available details regarding your current and/or past support arrangements. Have you ever made a private agreement with the other parent for child support? Yes If yes, Amount: $ every week two weeks month, beginning on No Are there any court actions pending in any state to establish or enforce support for your child(ren)? Yes No If yes, court (county, state): . date filed: Do you have an existing court order for child support? Yes No $ every week two weeks month starting on What court entered this order (County, State)? , The current support order requires payments to be made (check one) directly to me to a child support enforcement agency (County, State) , by income withholding directly to me by income withholding to a child support enforcement agency (County, State) CS500 , American LegalNet, Inc. www.FormsWorkFlow.com SECTION II - APPLICANT INFORMATION APPLICANT PERSONAL INFORMATION - Please complete this information about yourself Last Name: Date of Birth Social Security Number or TAX First Name: Identification Number Middle Name: Suffix: Maiden Name and/or Other Names used U.S. Citizen Yes No If No, What Country? Alien Registration No. Ethnicity: Sex: Hispanic Male Non-Hispanic Female Race: White Black American Indian, Eskimo Or Aleutian Asian or Pacific Islander Hispanic Other Primary spoken language Do you need an interpreter? Yes No If yes, specify language Home Phone Drivers License number Cell Phone Issuing State Email Address: Home Address City State Zip Code Mailing Address if different from home address City State Zip Code Your current Marital Status: Married Divorced Civil Union Separated Widowed Are you married to the parent of the child(ren)? No If yes, Date: City, State of Marriage Never Married May we contact you at work? Yes No CS500 Single Yes Are you divorced from the parent of the child(ren)? Yes No If yes, Date: City, State of Divorce APPLICANT EMPLOYMENT INFORMATION Employer Name Self-employed (company name) Employer Address County City Work Phone: Fax Number: Active Military Status Yes No Military Branch State Zip Code Work Email ID: American LegalNet, Inc. www.FormsWorkFlow.com APPLICANT ATTORNEY INFORMATION Your Attorney's Name (if you have an attorney for this case) Phone: Fax: Email: Attorney's Address City State Zip Code SECTION III - PARENT INFORMATION PARENT PERSONAL INFORMATION- Please complete this information about the parent you are filing this application against Last Name: Social Security Number or First Name: TAX Identification Number: Middle Name: Suffix: Date of Birth Place of Birth: Sex: City: Male Female State: Country Maiden Name and/or Other Names used U.S. Citizen Yes No If No, What Country? Alien Registration No. Race: White Black American Indian, Eskimo Or Aleutian Asian or Pacific Islander Hispanic Other Ethnicity: Hispanic Non-Hispanic PARENT IDENTIFYING INFORMATION: Please complete this information about the parent you are filing this application against Hair Color: Eye Color: Height: Facial Hair: Balding Black Black Brown Weight: Blond Brown Blue Green Gray/White Red Gray Hazel None/Bald unknown Other Other Distinguishing Features (Scars, Marks, Tattoos, Glasses): CS500 American LegalNet, Inc. www.FormsWorkFlow.com PARENT CONTACT INFORMATION: Please complete this information about the parent you are filing this application against Primary spoken language Home Phone Drivers License number Does the parent need an interpreter? Yes No Cell Phone Issuing State If yes, specify language Email Address: Last Known Home Address Lives with: Other Name: Parent City Relative Friend State Alone Zip Code Spouse Last Known Mailing Address if different from home address City Is the parent currently incarcerated or institutionalized Yes No County State Zip Code If yes, provide details: Name of the prison/jail/institution: City,State: PARENT'S EMPLOYER INFORMATION - Please provide information , if known, about the parent you are filing this application against Employer Name Self-employed (enter company name) Phone Number: Address City Salary $ Type of work performed every week month Belong to Union? State Zip Code 2 weeks year Yes If Yes, Union Name No Local # Additional Employment Phone Number: Address City Salary $ every Type of work performed week month Military Service Branch: Zip Code 2 weeks year Yes No Army Navy Air Force Marines Coast Guard Duty Station: (Base/Post/Ship and City/State) CS500 State Status? Active Reserve Retired Discharged (mm/yyyy) (mm/yyyy) American LegalNet, Inc. www.FormsWorkFlow.com PARENT'S HEALTH CARE INFORMATION - Please provide information, if known, about the parent you are filing this application against Health insurance provider: Child(ren) named in this application covered? Employer 1 Employer 2 Yes No Policy Number: Date coverage began: PARENT'S FINANCIAL INFORMATION - Please provide information, if known, about the parent you are filing this application against Does the parent receive any of the following types of income? Unemployment Compensation Legal Settlement Income Pension Worker's Compensation Commissions Supplemental Security Income Other disability Public Assistance (Welfare) Other Income Source Parent Bank Account Number Veteran's Administration Pension Railroad Retirement Pension Investment Income Social Security Retirement Trust Income Social Security Disability Dividend Income Royalties Rental Income Annuities Lottery Winnings Savings Checking Bank Name and Address PARENT'S ATTORNEY INFORMATION- Please provide information, if known, about the parent you are filing this application against Parent Attorney's Name Phone Attorney's Address, City, State Zip Code Fax Email CS500 American LegalNet, Inc. www.FormsWorkFlow.com SECTION IV - CHILD(REN) INFORMATION INFORMATION ABOUT THE CHILD(REN). Please provide information for each child for whom you are seeking to establish paternity and/or establish a Child Support/Medical Support Order. CHILD : 1 Last Name: Date of Birth City/State of Birth: First Name: Middle Name: Suffix: Paternity established? Yes No Race: Ethnicity: White Black Hispanic Asian or Pacific Islander Hispanic Non-Hispanic American Indian, Eskimo Or Aleutian Other SSN#: 999-99-9999 Sex: Male Female CHILD : 2 Last Name: Date of Birth City/State of Birth: First Name: Middle Name: Suffix: Paternity established? Yes No Race: Ethnicity: White Black Hispanic Asian or Pacific Islander Hispanic Non-Hispanic American Indian, Eskimo Or Aleutian Other SSN#: 999-99-9999 Sex: Male Female CHILD : 3 Last Name: Date of Birth City/State of Birth: First Name: Middle Name: Suffix: Paternity established? Yes No Race: Ethnicity: White Black Hispanic Asian or Pacific Islander Hispanic Non-Hispanic American Indian, Eskimo Or Aleutian Other CS500 SSN#: 999-99-9999 Sex: Male Female American LegalNet, Inc. www.FormsWorkFlow.com CHILD : 4 Last Name: Date of Birth City/State of Birth: First Name: Middle Name: Suffix: Paternity established? Yes No Race: Ethnicity: White Black Hispanic Asian or Pacific Islander Hispanic Non-Hispanic American Indian, Eskimo Or Aleutian Other SSN#: 999-99-9999 Sex: Male Female CHILD : 5 Last Name: Date of Birth City/State of Birth: First Name: Middle Name: Suffix: Paternity established? Yes No Race: Ethnicity: White Black Hispanic Asian or Pacific Islander Hispanic Non-Hispanic American Indian, Eskimo Or Aleutian Other CS500 SSN#: 999-99-9999 Sex: Male Female American LegalNet, Inc. www.FormsWorkFlow.com SECTION V - APPLICANT FINANCIAL INFORMATION: Provide us with information about your income and financial situation. Complete this section only if you are requesting the establishment of a support order for the child(ren) listed on this application. The other parent will be asked to complete a similar form. The court uses the financial information on these forms to set the amount of child support. Additionally, it may be used to determine if the support award should be increased or decreased in the future. IMPORTANT: You must provide a copy of your most recent federal tax form or your three most recent pay stubs to verify your income. Self-employed persons and business owners must also provide a copy of the most recent federal tax forms for their business. If you are requesting a credit or deduction, you must provide proof of your expenses or obligations. Information about your Financial Status. Gross Weekly Income. Report your weekly gross income. Divide monthly income by 4.3 and bi-weekly income by 2.6. You will be required to provide proof of your income when requesting support establishment services. 1. Salary, wages, commissions, bonuses and other payments for services performed $ 2. Income from operating a business minus ordinary and necessary expenses $ 3. Social security disability $ 4. Social Security retirement $ 5. Veteran's Administration pension $ 6. Worker's compensation $ 7. Other pensions, disability or retirement income $ 8. Unemployment compensation $ 9. Interest, dividends, annuities or other investment income $ 10. Income from the sale, trade or conversion of capital assets $ 11. Income from an estate of a decedent (a will) $ 12. Alimony or separate maintenance from a previous marriage $ 13. Income from trusts $ 14. Other income (specify) $ 15. Other income (specify): $ Total Gross Income (add lines 1 through 15) $ CS500 American LegalNet, Inc. www.FormsWorkFlow.com Weekly Exemptions. Report the following deductions from your weekly income. 1. Number of tax exemptions claimed 2. Mandatory union dues $ 3. Mandatory retirement contributions $ 4. Health insurance premium (must include child(ren) named in the complaint) 5. List each alimony or child support order paid by you, if applicable. A) State and Case Number B) State and Case Number $ $ Other Dependent Deduction: Complete this section if (1) you are legally responsible for supporting a child or children other than those named in the support complaint or application, (2) the child or children are living with you and (3) you are requesting credit for the amount spent on raising the other child or children when the support award is calculated. You are legally responsible for all children that are yours by birth or adoption. Answer the questions about the other parent of the child or children (for example, your current spouse who is the biological father of at least one of your children). 1. Number of other legal dependents (you must provide proof of the legal relationship) 2. Number of tax exemptions that parent of the other child(ren) claims 3. Weekly gross income of the parent of the other child(ren) $ 4. Mandatory union dues of the parent of the other child(ren) $ 5. Mandatory retirement contributions of the parent of the other child(ren) $ 6. Health insurance premiums paid by the parent of the other child(ren) $ 7. Alimony or child support orders paid by the parent of the other child(ren) $ CS500 American LegalNet, Inc. www.FormsWorkFlow.com Credit for Child Care Expenses: Complete this section only if (1) you pay for work related child care for a child or children for whom you and the other parent share a legal responsibility to support and (2) you are requesting a credit for these expenses when your support amount is calculated. 1. Annual child care cost (if paid weekly multiply by 52; if monthly multiply by 12) Child care provider name Address City $ State Zip Code Income Received by the Child(ren) from the other parent: Complete this section if your child(ren) receive regular payments in the name of the other parent (e.g., social security supplements or veteran's benefits apportionment's). 1. Source of benefit(s); 2. Weekly amount of benefits (requires proof) $ Health Insurance Benefits. Provide the following information about your health insurance benefits. Health Insurance Provider: Includes child(ren) Policy Carrier: Yes No Date coverage began: CERTIFICATION I certify that the foregoing statements made by me are true to the best of my knowledge. I am aware that if any of the foregoing statements are wilfully false, I am subject to punishment. Date: CS500 Signature: American LegalNet, Inc. www.FormsWorkFlow.com SECTION VI - PARENT LOCATION INFORMATION BACKGROUND INFORMATION ON THE PARENT. Please provide information, if known, about the parent you are filing this application against. Does the parent have a criminal record? Yes No If yes, City: State: Date: Education: School/College Name City, State Date of Attendance: Does the parent belong to any professional/trade associations? Yes State Yes If yes, Name: City Does the parent have any professional/trade licenses? If yes, License Number: Type: No No Issuing State: PARENT'S FRIENDS AND RELATIVES - Please provide information, if known, about the parent you are filing this application against Maiden Name of the parent's mother Living Deceased Address: City State Zip Code Name of the parent's father Address: City State Living Spouse/Other - Name: Address: City State Deceased Zip Code Relationship: Zip Code Does the parent have any other children besides yours? Child Name Court Order State Yes No Other Parent Name on the order PARENT FINANCIAL ASSETS INFORMATION. Please provide information, if known. Does the parent own any homes or real estate? Yes No If yes, please provide the address below. Address of Property (address, city, state, zip code): Address of Property (address, city, state, zip code): Does the parent own a motor/recreational vehicle? If Yes, please identify below, about the parent you are filing this application against. Yes No Make Model Color State where registered License No Make Model Color Does the parent own a boat? If Yes, please identify below. Make Registration No. CS500 State where registered License No Yes No Moored at: American LegalNet, Inc. www.FormsWorkFlow.com PARENT PAST EMPLOYMENT INFORMATION List the other parent's past employer(s), if known, about the parent you are filing this application against Employer Name Start Date: End Date: Address: Employer Name City State Start Date: Zip Code End Date: Address: City State Zip Code CHILD SUPPORT SERVICES APPLICATION FULL SERVICES - Check if requesting full IV-D Child Support Services FULL IV-D CHILD SUPPORT SERVICES ($6 Fee) (This agency will furnish the appropriate services for location; paternity, support and/or medical support establishment; and enforcement actions to which you are entitled.) OTHER SERVICES - Please check if not requesting full services Monitoring Services Only ($25 Annual Fee) (The selection of this service means that certain enforcement options will not be available.) AUTHORIZATION This portion of the application gives us permission to work on your case on behalf of your child(ren). You also agree to cooperate with us and follow the rules of the program. Again, if you do not understand this section, please ask the Child Support Agency's staff to explain it to you. By signing this application, I agree to the following: (1) The Child Support Agency may pursue and use all sources of information legally available to support its investigation of my case and perform the services that I have requested; (2) I will cooperate with the Child Support Agency in its efforts to provide the requested services and comply with the obligee's responsibilities listed in Part B of this application; (3) I will not accept court ordered support payments directly from the obligor or, if any are received, I will immediately forward them to the New Jersey Family Support Payment Center (NJFSPC); (4) I am not entitled to interest on any child support payment for the time it is held in the NJFSPC bank account pending distribution; (5) In accordance with N.J.S.A. 2A:17-56.60, the Child Support Agency may use my Social Security Number as an internal identifier for all child support and paternity purposes. I understand that my Social Security Number, my address and personal information about myself will remain confidential unless I authorize its release; and The Child Support Agency may terminate my case if I fail to cooperate or conform to the responsibilities documented in this application. Date Applicant's Signature Applicant's Name (Please Print) CS500 American LegalNet, Inc. www.FormsWorkFlow.com