DR-16 (rev. 8/99) Montgomery County Revised April 2016 Montgomery County Support Enforcement Agency New Case Number Work Sheet This is the information necessary to enter a case into the SETS system up to the point of the SESO (Support Order) screen. It is vital that we get as much of this information as possible so that we can properly clear the participants and load the case into the SETS system. Court Order #:_______________ SETS Case #: ___________________ (DF) (P1) (P2) SEA Case #: ______________ (PL) Judge _________________ (DF) (P1) (P2) Custodial Parent/Caretaker Information: (PL) Name Address1 Address2 City State Birthdate Race Employer Emp Add1 Emp Add2 City State Insured? Begin Date: Insurance Co Ins Addr1 City/State/Zip Plan Type Medical Dental Drug Emp Assistance Uninsured Expenses Child Information: First Name Middle Name Absent Parent Information: Name Address1 Address2 City Zip Code SSN Sex Phone # State Birthdate Race Employer Emp Add1 Emp Add2 City Zip Code SSN Sex Phone # Zip Code Insurance available? Plan Type Group Indiv State Insured? Begin Date: Insurance Co Ins Add1 City/State/Zip Zip Code Insurance available? Plan Type Group Indiv Plan Name Group # Policy # Plan Type Medical Dental Drug Emp Assistance Plan Name Group # Policy # Obligee Percentage: % Obligor Percentage: % Last Name Birthdate Social Security Number Disabled? Pat Est? BOW? Date entered into SETS:________________ Date Skeleton on COS-E: __________________ DEO Initials: ____________ Remember: You only need to build one case in SETS if the order is for both Child and Spousal Support. Therefore only one SEA Number is needed. Make sure you comment the COS-E IM Screen with the SETS Case Number and close it properly on the IG screen. Rev. 8/30/99 American LegalNet, Inc. www.FormsWorkFlow.com