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SIMPLIFIED APPLICATION FOR CHILD SUPPORT SERVICES

 
If the children named in the application have different noncustodial parents, a separate application must be completed for each noncustodial parent.
Applicant Name
Person completing this form
NOTE: The custodial party is the person or party who has primary custody of the minor children.
NAME:   Last
First
Middle
Suffix
Maiden Name
Enter if appropriate
Relationship to Children
ADDRESS:   Street
City
State
Zip
PHONE:   Home
Work
Cell
Prefer
|
E-Mail Address
Current Spouse Name
 
Tribal Member
Tribe Name
 
Social Security #
Driver License #
State
Birthdate or Age
If the Birthdate is unknown, provide an approximate age
If the Birthdate is unknown, provide an approximate age
Place of Birth
Race
Primary Language
Primary Language spoken in home
Employed
Employer
Job Title
job Title or Occupation
Gross Monthly Earnings
ADDRESS:   Street
Present Employer Address
City
Present Employer Address
State
Zip
Health Insurance Available for Children
Relative/Friend Name
Tel #
Does the custodial party currently live with the noncustodial parent?
(If "no" give date and address last lived in together)
Date
If Custodial Party currently DOES NOT live with the Noncustodial Parent then provide last lived together date
ADDRESS:   Street
If Custodial Party currently DOES NOT live with the Noncustodial Parent then provide last lived together address
City
If Custodial Party currently DOES NOT live with the Noncustodial Parent then provide last lived together address
State
Zip
If married, provide Date and Place of marriage
Date of Marriage to Noncustodial Parent
County
State
If Divorced, provide Date and Place of divorce
Date of Divorce
County
State
If parents were NOT married, please answer questions 1-4 below.
  1. Has noncustodial parent ever lived in California?
When
Where
  1. Has noncustodial parent ever worked in California?
When
Where
  1. Was a Paternity Declaration signed at a California hospital or agency?
Where
  1. Was a Paternity Judgment established?
Where
 
Have services been provided by another child support agency?
 
Serviced From To
City
State
Received Cash Aid?
Have the minor children received cash aid? (Welfare)
 
Is the noncustodial parent court ordered to pay child support for the child(ren) named below?
 
Court Order #
Amount
 
Date
County
State
List full names of all minor children by this noncustodial parent (If child is not yet born, provide expected date of birth).
A separate application is required for children from another noncustodial parent
 
Expected Date of Birth for Unborn Child(ren)
 
Name
Sex
Birthdate
Birthplace (City and State)
Conceived
in State
Social Security Number
Child(ren) Living With You
List full names of other minor child(ren) NOT related to this noncustodial parent
Name
Birthdate
Child(ren) Living With You
Comment
NAME:   Last
First
Middle
Suffix
Maiden Name
Enter if appropriate
Relationship to Children
Other Names
Other Names or Aliases of Noncustodial Parent
ADDRESS:   Street
City
State
Zip
Enter whether the specified address is current or was current as of date
PHONE:   Home
Work
Cell
Place of Birth
E-Mail Address
Gender
Tribal Member
Tribe Name
Social Security #
Driver License #
State
Birthdate or Age
If the Birthdate is unknown, provide an approximate age
 
Currently on probation or parole?
Currently in jail or prison?
If YES, provide information below:
 
Date
Agency
City
State
Offense
Is the noncustodial parent a US citizen?
Country of Citizenship
if is NOT a US citizen, please provide the Country of Citizenship
PHYSICAL DESCRIPTION:   Photo:
Race
Complexion
Primary Language
Hair
Height
Eyes
Weight
Identifying Features
Please provide marks, scars tatoos etc.
Employed
Employer
Enter whether the specified employer is current or was current as of date
ADDRESS:   Street
Noncustodial Parent's Present Employer Address
City
Noncustodial Parent's Present Employer City
State
Zip
 
Health Insurance Available for Children
Gross Monthly Earnings
 
If unemployed or present employer is unknown, give name, address and telephone number of last employment below.
Last Employer
Name of Noncustodial Parent's Last Employer
Tel
Noncustodial Parent's Last Employer Telephone Number (include area code)
Job Title
Noncustodial Parent's usual occupation, trade, job title or skills
ADDRESS:   Street
Noncustodial Parent's Last Employer Address
City
Noncustodial Parent's Present Employer City
State
Zip
Active Military:
Service Branch
What Branch of the Service?
Union Member:
Is the Noncustodial Parent a Labor Union Member?
Union Name
Name and Number of Union
ADDRESS OF UNION:   Street
City
State
Zip
Self-Employed:
Business Name
If Self-Employed, what is the name of the business?
Gross Monthly Earnings
Steady Worker:
If Self-Employed, is a Steady Worker?
If NO, explain:
List any other sources of income or assets.
(For example, Veterans Affairs benefits, Social Security Disability, interest, dividends, trust, vehicles, boats, real estate, etc.)
MOTHER'S MAIDEN NAME:   Last
First
Tel
MOTHER'S ADDRESS:   Street
City
State
Zip
FATHER'S NAME:   Last
First
Tel
FATHER'S ADDRESS:   Street
City
State
Zip
Name and address of current spouse, friend, or relative.
Name
Relationship
Street Address, City, State, Zip Code
Telephone Number
 
 
 
 
 
 
 
Is there visitation with the children?
If "YES", how many times per month?
 
 
Is there any other child support obligation(s)?
If "YES", please provide amount: $
 
 
Is there any other minor child(ren) in the home?
If "YES", how many children?
 
 
Present marital status:
 
I request the services of the Department of Child Support Services to assist me in the following efforts: (Mark all that apply).