CHRIS DANIEL, HARRIS COUNTY DISTRICT CLERK CHILD SUPPORT DEPARTMENT 1115 CONGRESS, ROOM 10 HOUSTON, TEXAS 77002 Phone No. (713) 755-6077 Fax No. (713) 755-4359 LOCATION VERIFICATION FORM FOR FUNDS HELD AWAITING ADDRESSES (PLEASE PRINT) DATE: ___________________ CAUSE #__________________________________ PAYOR NAME:________________________________________ SSN:_____________________ PAYEE NAME:________________________________________ SSN:_____________________ ________________________________________________________________________ PREVIOUS ADDRESS CITY STATE ZIP ________________________________________________________________________ CURRENT ADDRESS CITY STATE ZIP HOME PHONE: (_____)_______________ BUSINESS PHONE:(____)______________ NUMBER OF CHILDREN:____________ NAME: ______________________________________________ DOB: ____________ NAME: ______________________________________________ DOB: ____________ NAME: ______________________________________________ DOB: ____________ NAME: ______________________________________________ DOB: ____________ NAME: ______________________________________________ DOB: ____________ PAYEE SIGNATURE: ___________________________________________________________ **Please attach a copy of your state issued picture ID along with the above information FINCS11 REV 03/29/00 American LegalNet, Inc. www.FormsWorkFlow.com