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Simplified Application (Required)
Income & Expense (Required)
Family Violence Questionnaire
Visitation Verification
Child Care Verification
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
I am the Custodial Party
I am the Non-Custodial Parent
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
Father
Mother
Other
ADDRESS: Street
City
State
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UM
UT
VA
VI
VT
WA
WI
WV
WY
Zip
PHONE: Home
Work
Cell
Prefer
AM
PM
|
Home
Work
Cell
E-Mail Address
Current Spouse Name
Tribal Member
Yes
No
Tribe Name
Social Security #
Driver License #
State
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UM
UT
VA
VI
VT
WA
WI
WV
WY
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
African
Alaskan Native
Alaskan Native/Native American
Armenian
Asian Indian
Asian
Black
Cambodian
Chinese
Filipino
Guamanian
Hawaiian
Hispanic
Japanese
Korean
Laotian
Multi-Racial
Native American
No Race Given
Other
Pacific Islander
Samoan
Unknown
Vietnamese
White
Primary Language
Primary Language spoken in home
Female
Male
Employed
Yes
No
Employer
Job Title
job Title or Occupation
Gross Monthly Earnings
ADDRESS: Street
Present Employer Address
City
Present Employer Address
State
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UM
UT
VA
VI
VT
WA
WI
WV
WY
Zip
Health Insurance Available for Children
Yes
No
Relative/Friend Name
Tel #
Does the custodial party currently live with the noncustodial parent?
(If "no" give date and address last lived in together)
Yes
No
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
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UM
UT
VA
VI
VT
WA
WI
WV
WY
Zip
Married
Never Married
If married, provide Date and Place of marriage
Date of Marriage to Noncustodial Parent
County
State
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UM
UT
VA
VI
VT
WA
WI
WV
WY
Divorced
No Divorce
If Divorced, provide Date and Place of divorce
Date of Divorce
County
State
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UM
UT
VA
VI
VT
WA
WI
WV
WY
If parents were NOT married, please answer questions 1-4 below.
Has noncustodial parent ever lived in California?
Yes
No
When
Where
Has noncustodial parent ever worked in California?
Yes
No
When
Where
Was a Paternity Declaration signed at a California hospital or agency?
Yes
No
Don't Know
Where
Was a Paternity Judgment established?
Yes
No
Don't Know
Where
Have services been provided by another child support agency?
Yes
No
Serviced From
To
City
State
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UM
UT
VA
VI
VT
WA
WI
WV
WY
Received Cash Aid?
Yes
No
Have the minor children received cash aid? (Welfare)
Is the noncustodial parent court ordered to pay child support for the child(ren) named below?
Yes
No
Pending
Court Order #
Amount
Weekly
Monthly
Date
County
State
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UM
UT
VA
VI
VT
WA
WI
WV
WY
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
If child is not yet born, check here
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
M
F
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UM
UT
VA
VI
VT
WA
WI
WV
WY
Yes
No
List full names of other minor child(ren) NOT related to this noncustodial parent
Name
Birthdate
Child(ren) Living With You
Yes
No
Comment
NAME: Last
First
Middle
Suffix
Maiden Name
Enter if appropriate
Relationship to Children
Father
Mother
Other Names
Other Names or Aliases of Noncustodial Parent
ADDRESS: Street
City
State
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UM
UT
VA
VI
VT
WA
WI
WV
WY
Zip
Current Now
Current As Of
Enter whether the specified address is current or was current as of date
PHONE: Home
Work
Cell
Place of Birth
E-Mail Address
Gender
Female
Male
Tribal Member
Yes
No
Tribe Name
Social Security #
Driver License #
State
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UM
UT
VA
VI
VT
WA
WI
WV
WY
Birthdate or Age
If the Birthdate is unknown, provide an approximate age
Currently on probation or parole?
Yes
No
Currently in jail or prison?
Yes
No
If YES, provide information below:
Date
Agency
City
State
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UM
UT
VA
VI
VT
WA
WI
WV
WY
Offense
Is the noncustodial parent a US citizen?
Yes
No
Country of Citizenship
if is NOT a US citizen, please provide the Country of Citizenship
PHYSICAL DESCRIPTION: Photo:
Race
African
Alaskan Native
Alaskan Native/Native American
Armenian
Asian Indian
Asian
Black
Cambodian
Chinese
Filipino
Guamanian
Hawaiian
Hispanic
Japanese
Korean
Laotian
Multi-Racial
Native American
No Race Given
Other
Pacific Islander
Samoan
Unknown
Vietnamese
White
Complexion
Primary Language
Hair
Height
Eyes
Weight
Identifying Features
Please provide marks, scars tatoos etc.
Employed
Yes
No
Employer
Current Now
Current As Of
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
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UM
UT
VA
VI
VT
WA
WI
WV
WY
Zip
Health Insurance Available for Children
Yes
No
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
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UM
UT
VA
VI
VT
WA
WI
WV
WY
Zip
Active Military:
Yes
No
Service Branch
What Branch of the Service?
Union Member:
Yes
No
Is the Noncustodial Parent a Labor Union Member?
Union Name
Name and Number of Union
ADDRESS OF UNION: Street
City
State
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UM
UT
VA
VI
VT
WA
WI
WV
WY
Zip
Self-Employed:
Yes
No
Business Name
If Self-Employed, what is the name of the business?
Gross Monthly Earnings
Steady Worker:
Yes
No
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
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UM
UT
VA
VI
VT
WA
WI
WV
WY
Zip
FATHER'S NAME: Last
First
Tel
FATHER'S ADDRESS: Street
City
State
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UM
UT
VA
VI
VT
WA
WI
WV
WY
Zip
Name and address of current spouse, friend, or relative.
Name
Relationship
Street Address, City, State, Zip Code
Telephone Number
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UM
UT
VA
VI
VT
WA
WI
WV
WY
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UM
UT
VA
VI
VT
WA
WI
WV
WY
Is there visitation with the children?
Yes
No
If "YES", how many times per month?
Is there any other child support obligation(s)?
Yes
No
If "YES", please provide amount: $
Is there any other minor child(ren) in the home?
Yes
No
If "YES", how many children?
Present marital status:
Single
Married
Divorced
Separated
Living with another person
I request the services of the Department of Child Support Services to assist me in the following efforts: (Mark all that apply).
Establish paternity
Modify an existing child support order
Obtain a child support order
Obtain an order for medical insurance
Enforce an existing child and spousal support order (including past due)
Enforce an existing medical insurance order
No medical insurance enforcement needed at this time. The children have satisfactory medical insurance coverage through:
Custodial Parent
Noncustodial Parent
I am applying for support services under the Child Support Program of Title IV-D of the Social Security Act. I declare under penalty of perjury (Penal Code, Section 118) that this questionnaire has been examined by me and to the best of my knowledge and belief it is true and correct.
PRINT NAME FOR SIGNATURE
Typing your name is equivalent to your handwritten signature
DATE
Enter Today's Date for Signature Date
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