DR-16 (rev. 8/99) 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 #: ___________________ Custodial Parent/Caretaker Information: (PL) (DF) (P1) (P2) SEA Case #: ______________ Absent Parent Information: Name (P2) Address2 City (P1) Address1 Address2 (DF) Name Address1 (PL) Judge _________________ City State Zip Code State Zip Code Birthdate SSN Birthdate SSN Race Sex Race Sex Phone # Employer Employer Emp Add1 Emp Add1 Emp Add2 Emp Add2 City Phone # City State Zip Code State Zip Code Insured? Insurance available? Insured? Insurance available? Begin Date: Plan Type Group Indiv Begin Date: Insurance Co Indiv Ins Add1 City/State/Zip Group Insurance Co Ins Addr1 Plan Type City/State/Zip Plan Type Plan Name Group # Policy # Plan Type Medical Drug Emp Assistance Policy # Dental Drug Group # Medical Dental Plan Name Emp Assistance Uninsured Expenses Obligee Percentage: % Obligor Percentage: % Child Information: First Name Middle Name 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 2001 © American LegalNet, Inc.