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CUSTODIAL PARENT (parent collecting child support)

First Name

Last Name

Middle Name

Address

City, State

Zip

Home Phone

Mobile Phone

Work Phone

Court Cause or Case Number and County

Atty. General CIN #

Date of Birth

Social Sec #

Drivers Lic. #

Are you/have you collected TANF?

NON CUSTODIAL PARENT (parent owing child support). Fill out as much as possible and H.I.A. will help you with the rest.

First Name

Last Name

Middle Name

Address

City, State

Zip

Home Phone

Mobile Phone

Work Phone

Date of Birth

Social Sec #

Drivers Lic. #

Is NCP currently employed? (if YES, where?)

NCP's training and usual type of employment

Children

Child 1

First Name

Last Name

Middle Name

Date of Birth

Social Sec. #

Male/Female

Child 2

First Name

Last Name

Middle Name

Date of Birth

Social Sec. #

Male/Female

Child 3

First Name

Last Name

Middle Name

Date of Birth

Social Sec. #

Male/Female

Additional Information: