REGISTRATION STATEMENT
Responding IV-D Case No. ___________________________________________ Responding Docket No. ______________________________________________ I. Case Summary (Background of this Matter: Court / Administrative Actions) State and County Issuing Order Tribunal Case No. Initiating IV-D Case No. ______________________________ Initiating Docket No. ________________________________
Date of Support Order
Support Amount/Frequency $ II. Mother Information Full Name and Aliases (First, Middle, Last) [
Date of Last Payment
Amount of Arrears $
Period of Computation ________________ thru ______________ Date Date Employer (Name, Street, City, State, Zip)
] Obligor [ ] Obligee Address (Street, City, State, Zip)
SSN: III. Father Information Full Name and Aliases (First, Middle, Last)
[
] Obligor [ ] Obligee Address (Street, City, State, Zip)
Employer (Name, Street, City, State, Zip)
SSN: IV. Caretaker (If Not a Parent) Full Name and Aliases (First, Middle, Last)
Relationship to Child(ren) _____________________________________________________ Address (Street, City, State, Zip)
SSN: V. Additional Case Information This order is registered in the following states:
Description and location of any property not exempt from execution:
Other:
VI. Verification / Certification Under penalties of perjury, all information and facts concerning the arrearage accrued under this order are true to the best of my knowledge and belief.
__________________________________ Date
_________________________________________________________________________________ [ ] Party seeking Registration [ ] Records Custodian
__________________________________ Sworn to and Signed Before Me This Date, County/State
Registration Statement
______________________________________________________ Notary Public, Court/Agency Official and Title
____________________ Commission Expires
OMB No. 0970 - 0085
Page 1 of 1