INFORMATION SHEET CLERMONT COUNTY CHILD SUPPORT ENFORCEMENT 2400 CLERMONT CENTER DRIVE, SUITE 107 BATAVIA, OHIO 45103 (513) 732-7248 FAX: (513) 732-7446 In order to process your account, the following shall be completed and attached to your court order.. JUDGE MICHAEL J. VORIS MAGISTRATE _________________ DATE: _______________________ COURT CASE #_______________ ********************************************************************************************************************************* NAME OF PERSON ORDERED TO PAY: ___________________________________________ CURRENT ADDRESS: _________________________________________________________________________ PHONE #: _____________________ CELL PHONE #:____________________ BIRTHDATE:________________ SOCIAL SECURITY NUMBER:__________________ E MAIL ADDRESS: ______________________________ NAME AND ADDRESS OF EMPLOYER: __________________________________________________________ _________________________________________ TELEPHONE NUMBER: _____________________________ *********************************************************************************************************************************** NAME OF PERSON TO RECEIVE PAYMENTS: _____________________________________________________ CURRENT ADDRESS: _________________________________________________________________________ PHONE #: __________________ CELL PHONE #:__________________ BIRTH DATE: _____________________ SOCIAL SECURITY NUMBER: ______________________ E MAIL ADDRESS: ___________________________ NAME AND ADDRESS OF EMPLOYER: ___________________________________________________________ _________________________________________ TELEPHONE NUMBER: _______________________________ ********************************************************************************************************************************** INSURANCE COMPANY CLAIMS SENT TO: (If different) Name: _____________________________________ _______________________________________________ Address: ___________________________________ _______________________________________________ ___________________________________________ _______________________________________________ City/State/Zip: _______________________________ _______________________________________________ Policy Number: ______________________________ Group Number: __________________________________ NAME OF PERSON ORDERED TO PROVIDE MEDICAL INSURANCE: MINOR CHILD(ren) of this order, who are covered under the insurance policy. _________________________________ DOB: _____________ SSN: ____________________________________ _________________________________ DOB: _____________ SSN: ____________________________________ _________________________________ DOB: _____________ SSN: ____________________________________ _________________________________ DOB: _____________ SSN: ____________________________________ _________________________________ DOB: _____________ SSN: ____________________________________ _________________________________ DOB: _____________ SSN: ____________________________________ Is insurance provided by Non Participating Participant (NPP)? (Example: Step Parent) ______Yes ______ No If Yes: Name of Party: __________________________________________________________________________ SS#: ________________________ DOB:_____________________ Employer Name & Address:______________________________________________________________________ Rev. 10/2008 Form 509-4 American LegalNet, Inc. www.FormsWorkflow.com