Application for Child Support Services - Indiana
Page 5 of 6
DEPENDENT INFORMATION (continued)
County of court
State of court
Court cause number
Do you have a private attorney handling paternity and/or support matters for the child of this application?
Yes No
Name of attorney (first, last, and suffix)
Telephone number of attorney
( )
Do you have a court ordered support obligation for child(ren) listed on the application?
Yes No Unknown (If yes, complete the following information.)
Name of court
County of court
State of court
Court cause number
Is there a court order for custody?
Yes No (If yes, complete the following box.)
Name of person granted custody by court
PARTICIPANT INFORMATION FOR OTHER PARENT
Full name of other parent (last, first, middle)
Relationship to Dependents on this application (e.g. Mother, Father, Guardian, Other)
Alias (last, first, middle)
Maiden
Previous
Nickname
Last known mailing address (number and street, PO Box, rural route number, apartment, or room number, city, state and ZIP code - please include County)
Last known street address:
Check here if the same. (If different, complete the information below.)
Mailing address (number and street, rural route number, apartment. or room number, city, state and ZIP code - please include County)
Country (If outside of US, complete the following box.)
International code
Telephone number (home)
( )
Telephone number (work)
( )
Telephone number (mobile/other)
( )
E-mail address
Date of birth (month, day, year)
Approximate age range
Gender
Race
Social Security number* / ITIN
Alien Identification number
Is English primary language?
Yes No (If no, please provide)
Primary language
Interpreter needed?
Yes No
Is special assistance needed?
Yes No (If yes, please specify)
Specify assistance here (i.e. Physical, Hearing Impaired, Other)
Is the other parent currently incarcerated?
Yes No
County of incarceration
State of incarceration
Name of Department of Correction facility
Height
Weight
Hair color
Facial hair
Color of eyes
Glasses
Distinguishing marks / tattoos
Other identifying characteristics
Last known employer
Telephone number of employer
( )
Address of employer (number and street, city, state and ZIP code - please include Country)
International Code
Military Status
Never Active Reserve Retired
List Military Branch here (Army, Navy, Marines, Air Force or Coast Guard)
Deployed Overseas?
Yes No
Is the other parent deceased?
Yes No (If yes, please complete information.)
Date of death (month, day, year)
Place of death (city, county, state, country)
Photo available of other parent?
Yes No
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