Child Support Information Sheet Sensitive/Confidential Information Cause Number Court Number OAG Case Number (if available) OBLIGOR (PAYOR) INFORMATION OBLI G EE (PAYEE) INFORMATION Last Name: Last Name: First Name: First Name: Middle Name: Middle Name: Home Address: Apt Home Address: Apt City: State: Zip Code: City: State: Zip Code: Soc. Sec. No: DOB: Sex: M/F Soc. Sec. No: DOB: Sex: M/F Phone: (H) (W) Phone: (H) (W) Email Address: Email Address: Drivers License No: ST: Drivers License No: ST: Relationship to Child(ren): Relationship to Child(ren): Employer: Employer: Address: Address: City: State: Zip Code: City: State: Zip Code: Obligor Family Violence Indicator (FV) Oblig ee Family Violence Indicator (FV) Check if individual above or child ( ren ) are victim s of family violence. Check if individual above or child ( ren ) are victim s of family violence . DATE OF BIRTH (MM/DD/YYYY ) SEX SOCIAL SECURITY NUMBER M/F M/F M/F M/F OBLIGATION SUMMARY Regular Child Support: $ (monthly, semi - monthly, biweekly, weekly) Begin Date: , 20 Cash Medical Support: $ (monthly, semi - monthly, biweekly, weekly) Begin Date: , 20 Medical Insurance: Obligor provides Obligee provides Both Responsible Not addressed Spousal and/or Arrears Support: $ (monthly, semi - monthly, biweekly, weekly) Begin Date: , 20 *Obligor Attorney Phone *Obligee Attorney Phone *Attorney/Obligor/Obligee may be contacted if questions occur during account establishment. Form prepared by: Phone: Date: , 20 American LegalNet, Inc. www.FormsWorkFlow.com