*03EN008E-001* OKLAHOMA DEPARTMENT OF HUMAN SERVICES Family Violence - Address of Record Statement . Please print the following identification information. Name of custodian (Person receiving support) Last First Middle Social Security number* Name of noncustodial parent (Person ordered to pay support) Last First Middle Social Security number* Oklahoma child support case number District court case number . FGN: County State *Social Security numbers will only be used for child support purposes. Please complete the following information: I, , state that: Type or print your name family violence IS a risk to me or my child(ren) from Name of potentially dangerous person family violence IS NOT an issue in my case. Required address (address of record) – a public address where you will accept payments, legal and other official papers by regular mail, possibly your private attorney’s address, if you have one. This address will be printed in legal/court documents and therefore, may be provided to the other parent or party. If family violence is an issue, this address of record must be different from a home address. Street or P.O. Box City State Zip I am claiming family violence is a risk in my case. Please use the following address as my confidential location address that will not be released or appear in court documents: Street or P.O. Box City Would you like information concerning electronic deposit of payments? State Yes Zip No I state under penalty of perjury under the laws of Oklahoma that the foregoing is true and correct. Signature Date and place RETURN WITH APPLICATION FOR SERVICES, OR IF COMPLETING SEPARATELY, SEND TO: CSED, Central Case Registry Attn: Address Disclosures P. O. Box 528805 Oklahoma City, OK 73152-8805 You must include a copy of a photo I.D. Card OKDHS REVISED 1-30-2003 03EN008E (CSED-8) American LegalNet, Inc. www.FormsWorkflow.com