LICKING COUNTY CHILD SUPPORT ENFORCEMENT AGENCY INFORMATION FORM CARETAKER(S) 1. Name (Primary): First Middle Last Birth Date: Name (Secondary): Social Security Number: Marital Status: First Middle Last Birth Date: 2. 3. Social Security Number: Marital Status: Caretaker's Relationship to child: Who has Legal Custody of the child?: Date Custody Received: Docket Number: Court: County and State: 4. Your Address: Street Mailing Address: Previous Address: Phone Number: Home City State Zip , Message , Contact Person 5. Your Current or Most Recent Employer: Full Address: Number and Street City State Zip Phone Suite Insurance Coverage: Access to Private Medical Insurance? Insurance Company: Licking County Child Support Enforcement Agency 65 East Main Street P.O. Box 338 Newark, Ohio 43055-0338 (740)349-6575 or 1-800-513-1128 American LegalNet, Inc. www.USCourtForms.com CHILD 1. 2. 3. 4. Name: First Middle Last Male Birth Date: Address: Female Race: Birth Place: SSN: Street City State Zip Previous Address: Street City State Zip 5. 6. 7. Born out of wedlock? Yes No Yes Yes No No Yes No Is child deemed disabled? Yes No Is child covered by medical insurance? Is there a support order for this child? Is child living with an Ohio Welfare Family recipient? CHILD 1. 2. 3. 4. Name: First Middle Last Male Birth Date: Address: Female Race: Birth Place: SSN: Street City State Zip Previous Address: Street City State Zip 5. 6. 7. Born out of wedlock? Yes No Yes Yes No No Yes No Is child deemed disabled? Yes No Is child covered by medical insurance? Is there a support order for this child? Is child living with an Ohio Welfare Family recipient? 2 NON-RESIDENTIAL PARENT (MOTHER) American LegalNet, Inc. www.USCourtForms.com Complete pages 3 through 5 with information regarding the mother of the child(ren) 1. 2. 3. Name: First Middle Last Maiden Other Names Used: Address (Current or Last Known (Circle)): Street City State Zip Address Verified? 4. 5. 6. 7. Birth Date: Yes No How? Birthplace: Social Security Number: Phone Number: Last Known Employer for Non-Residential Parent (Does he/she still work there?) Employer's Name: Full Address: Street City State Zip Phone: Type of Business: Date Started Job: Gross Pay Per Month: $ Insurance Coverage: Access to Private Medical Insurance? Who paid birthing expenses: 8. Fax: Non-Residential Parent's Position: If no longer employed, date left job: Union Name: Insurance Company: Insurance / Self / State of Ohio / Other: What other source(s) of income does the Non-Residential Parent have? (give amount) Unemployment Benefits: Worker's Comp Benefits: Disability Benefits: Other (Explain): 3 $ $ $ Social Security Benefits: Veteran Benefits: Retirement Benefits: $ $ $ $ 9. What assets does the Non-Residential Parent have? (Describe) American LegalNet, Inc. www.USCourtForms.com Bank Accounts: Motor Vehicles: Make Model Year Real Property: Lic plate State Other (Explain): 10. Description of Non-Residential Parent: Male Female Race Height Weight Scars Birthmarks Hair Tattoos? ; Beard Mustache, any other distinguishing features? Eyes Does the Non-Residential Parent have: (Circle) If so, describe: Glasses 11. Non-Residential Parent's Level of Education: High School Attended: _________________________________ University or Technical School Attended: Degrees: Graduated? Yes No 12. Licenses? Drivers: Motorcycle: Chauffeurs: Professional: ___________________ What State: 13. Arrest Record? Date: Incarceration? Date: Probation / Parole? Probation/Parole Officer: Address: 14. Military Service: Dates (Circle One) Army Navy Air Force to Marines Honorable / Dishonorable Discharge Reserves National Guard Where: Where: Where? Charge: Charge: Dates: Phone: Gross Amount: $ Contact Phone Number: 4 15. Non-Residential Parent's Family: American LegalNet, Inc. www.USCourtForms.com Father: Address: Mother: Married Name / Maiden Name Telephone Number: Telephone Number: Address: Is the Non-Residential Parent a minor? If Yes, with whom do they reside? Brother / Sister / Friend (Circle One): Address: 16. Telephone Number: Marital Status Spouse/Friend Yes No Non-Residential Parent's Current: Spouse / Girlfriend / Boyfriend (Circle One): Name: Address: Any Children in the Home: Ordered to pay child support to anyone else? What County, State? How Many? To Whom? Telephone Number: 17. Are the Non-Residential Parents currently residing together? If No, last address they shared: Yes No Date: Phone or Person? 18. 19. Last date of contact you had with this Non-Residential Parent: Additional Comments: 5 NON-RESIDENTIAL PARENT (FATHER) Complete pages 6 through 8 with information regarding the father of the child(ren) American LegalNet, Inc. www.USCourtForms.com 1. 2. 3. Name: First Middle Last Other Names Used: Address (Current or Last Known (Circle)): Street City Address Verified? Yes No State How? Birthplace: Zip 4. 5. 6. 7. Birth Date: Social Security Number: Phone Number: Last Known Employer for Non-Residential Parent (Does he/she still work there?) Employer's Name: Full Address: Street Phone: Type of Business: Date Started Job: Gross Pay Per Month: $ Insurance Coverage: Access to Private Medical Insurance? Who paid birthing expenses: Insurance / Self / State of Ohio / Other: City Fax: Non-Residential Parent's Position: If no longer employed, date left job: Union Name: Insurance Company: State Zip 8. What other source(s) of income does the Non-Residential Parent have? (give amount) Unemployment Benefits: Worker's Comp Benefits: Disability Benefits: Other (Explain): $ $ $ Social Security Benefits: Veteran Benefits: Retirement Benefits: $ $ $ $ 9. 6 What assets does the Non-Residential Parent have? (Describe) Bank Accounts: Real Property: American LegalNet, Inc. www.USCourtForms.com Motor Vehicles: Make Other (Explain): 10. Model Year Lic plate State Description of Non-Residential Parent: Male Female Race Height Weight Scars Birthmarks Hair Tattoos? ; Beard Mustache, any other distinguishing features? Eyes Does the Non-Residential Parent have: (Circle) If so, describe: Glasses 11. Non-Residential Parent's Level of Education: High School Attended: _________________________________ University or Technical School Attended: Degrees: Graduated? Yes No 12. Licenses? Drivers: Motorcycle: Chauffeurs: Professional: ___________________ What State: 13. Arrest Record? Date: Incarceration? Date: Probation / Parole? Probation/Parole Officer: Address: 14. Military Service: Dates (Circle One) Army Navy Air Force to Marin