NOTE: This form must be filed with all child support and paternity petitions. FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF ................................................................................. In the Matter of a Proceeding for Support Under Article G4 G5 of the Family Court Act Petitioner, FORM 4-5/5-1-d 8/2010 Docket No. PERSONAL INFORMATION FORM G Child Support G Paternity -against- Respondent. .................................................................................. NOTICE: You must include your full social security number and those of your children on this form. Social security numbers are confidential and will be disclosed only as required by law. If disclosure of your address and telephone number would pose an unreasonable health or safety risk to you or your children, you may request address confidentiality by filling out General Form GF-21 (Address Confidentiality Affidavit), which is available on-line at www.nycourts.gov. NAME OF PETITIONER OR ASSIGNOR:1 ______________________________________________________ ADDRESS (required): __________________________________________________________________ __________________________________________________________________ Should your address be kept confidential from the other party: Yes G No G TELEPHONE NUMBER: HOME: _______________ WORK: ______________ CELL: ______________ Should your phone number be kept confidential from the other party: Yes G No G SOCIAL SECURITY NUMBER (required): __________________ DATE OF BIRTH: _____________________ EYE COLOR: ____________ HAIR COLOR: ___________ HEIGHT: _________ WEIGHT _______ (M or F) EMPLOYER NAME: _______________________________________________________________________ ADDRESS: _______________________________________________________________________________ RESPONDENT’S NAME: ADDRESS (required): __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ TELEPHONE NUMBER: HOME: _______________ WORK: ______________ CELL: ______________ SOCIAL SECURITY NUMBER: _________________________ DATE OF BIRTH: _____________________ EYE COLOR: ____________ HAIR COLOR: ___________ HEIGHT: _________ WEIGHT _______ (M or F) EMPLOYER NAME: _______________________________________________________________________ ADDRESS: _______________________________________________________________________________ Children(s) Names 1 Date of Birth Social Security Number (M or F) In IV-D cases where rights have been assigned, give information as to assignor. American LegalNet, Inc. www.FormsWorkFlow.com Form 4-5/5-1-d Page 2 List any other names you or the other party may have been previously known by (i.e., maiden name, previous marriage name, etc.) PETITIONER: _____________________________________________________________________________ RESPONDENT: ___________________________________________________________________________ ARE YOU SCHEDULED IN ANY OTHER COURT OR CASE WITH THE PERSON YOU ARE FILING AGAINST? G YES – Court:__________________County: ________________ Docket or index number: __________________________ Date of next appearance: __________________________ G NO Dated: ____________________________ Signature of Petitioner ____________________________ Print or type name ____________________________ Signature of Attorney, if any ____________________________ Attorney’s Name (Print or Type) ____________________________ ____________________________ ____________________________ Attorney’s Address & Telephone Number American LegalNet, Inc. www.FormsWorkFlow.com