Address of Record and/or Family Violence Statement II. Address of Record and/or Family Violence Statement Completed by: Custodian Noncustodian Other Custodial Person (person with custody of child/ren) Full legal name, first Area code Phone number Middle Last Social Security number Area code Alternate phone number Email address Noncustodial Parent (person ordered to pay support) Full legal name, first Area code Phone number Address of Record Use the address below as my public mailing address where I will accept service of process in child support, visitation and custody actions by regular mail. This address will be printed in legal/court documents and provided to the other parent or party. Street or PO Box Family Violence Check the appropriate box Family violence IS NOT a risk to me or my child(ren). Family violence IS a risk to me or my child(ren) from: If family violence is a risk, provide your confidential home address. This information will NOT be released or appear in court documents. This address should be different from your address of record, if possible. Street or PO Box City Oklahoma State ZIP code Yes No City Oklahoma State ZIP code Middle Last Social Security number Area code Alternate phone number Email address Does the person above know your confidential address? I state under penalty of perjury under the laws of Oklahoma that this information is true and correct. Signature 03EN008E Date Place 11/21/2016 American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 2 Purpose Form 03EN008E, Address of Record and/or Family Violence Statement, is used to designate an Address of Record will be released upon request to the other parent or party, and it will be shown in legal documents. Complete a separate form for each child support case you have. When family violence is not claimed and your address of record is the same as your confidential home address, your address will be released and appear on child support and legal documents. Giving an address of record to CSS is required by law per Title 43 of the Oklahoma Statutes, section 112A. Instructions � Enter the names and Social Security numbers of the custodial person and noncustodial parent. Social Security numbers are only used for child support purposes. � Enter the Family Group Number (FGN)/CSS case number. � Enter Address of Record information � Check the appropriate box indicating whether family violence is or is not a risk in your case. This information will be documented in your case. � When family violence is a risk, enter the name of the person who is a risk to you or your child(ren). Provide your confidential contact information. Check whether the person listed as a risk already knows your confidential home address. � Sign and date the form. � make a copy of this form to keep for your records. Questions? Telephone (918) 295-3500 in the Tulsa area; (405) 522-2273 in the Oklahoma City area; or 1-800-522-2922 toll free. For TTY dial 711. If you or someone you know is a victim of domestic violence, please call the 24-hour Oklahoma Safeline: 1-800-522-SAFE (7233). 03EN008E 11/21/2016 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2