Child Support Enforcement Form - Arkansas
Questionnaire and Application
R1015
Page 5 of 7
City, State, Zip
Physical Description of the other parent:
Eye Color ________ Hair Color ___________ Height _________ Weight ________
Marks (tattoos, scars, piercings, etc.) ___________________________________
Race: ___Caucasian ___ African American ___ Hispanic ___ Asian
___ American Indian: Tribe ______________ ___ Other: ____________________
What are the names of the mother and father of the noncustodial parent, even if they are deceased?
Father’s full name: ______________________________________________________________________
Mother’s full name, including maiden name if known: __________________________________________
Does the noncustodial parent currently receive any of the following:
SSI? ___Yes ___No ___Not Known SSA/SSD? ___Yes ___No ___Not Known
VA Benefits? ___Yes ___No ___Not Known TEA? ___Yes ___No ___Not Known
Worker’s Compensation ? ___Yes ___No ___Not Known
Has the noncustodial parent ever been in the military?
___Yes ___No ___Not Known
If yes, what branch?__________________________
Has the noncustodial parent ever been in jail or
prison? ___Yes ___No ___Not Known
If yes, where? ______________________________
Does the noncustodial parent own a car? ___Yes ___No ___Not Known
Year _____ Make/Model ______________________ License Number _____________ State _______
If the noncustodial parent is currently unemployed, please provide the information for the last known
employer to the best of your knowledge:
Company name: ___________________________ Phone: __________________________
Address: _____________________________________________________________________
Is the noncustodial parent currently married? ___Yes ___No ___Not Known
If yes, list name of the current spouse: _______________________________
Is the other parent represented by an attorney? ___Yes ___No ___ Not Known
If yes, please provide the following information about the attorney:
Name: ____________________________________ Phone: _____________________
Address: _____________________________________________________________________
Where did the noncustodial parent attend high school? _______________________________
How did you and the noncustodial parent meet? _____________________________________
Please list any other information that you feel will help OCSE in working your case. For example: professional,
business, or a commercial driver’s license; other names he or she may use; address where his or her parents
reside; name of any other children the noncustodial parent may have.
How did you learn about our services? (Check all that apply)
__ Another state agency
__ Brochure
__ Child Care referral
__ Educational presentation
__ Expos and fairs
__ I am re-opening my case
__ Internet
__ Letter from OCSE
__ Newspaper /print ad
__ Radio
__ Referred by someone
__ Other-please explain __________
Signature ________________________________________ Date ________________
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