SETS – Child Support Information Form

Non-Residential Parent Name Non-Residential Parent Case Number Non-Residential Parent Street Address Non-Residential Parent City Non-Residential Parent State Non-Residential Parent Zip Non-Residential Parent Home Telephone Area Code Non-Residential Parent Home Telephone Phone Number Non-Residential Parent Work Telephone Area Code Non-Residential Parent Work Telephone Phone Number Non-Residential Parent Social Security Number Non-Residential Parent Date of Birth Non-Residential Parent Race Withholding Employer Name Withholding Employment Begin Date Withholding Worksite Street Address Withholding Worksite City Withholding Worksite State Withholding Worksite Zip Payroll Address Payroll City Payroll State Payroll Zip Payroll Contact Payroll Telephone Area Code Payroll Telephone Phone Number Financial Institution Street Address Financial Institution City Financial Institution State Financial Institution Zip Bank Account Number Account Type Financial Institution Telephone Area Code Financial Institution Telephone Phone Number Residential Parent Name Residential Parent Case Number Residential Parent Street Address Residential Parent City Residential Parent State Residential Parent Zip Residential Parent Home Telephone Area Code Residential Parent Home Telephone Phone Number Residential Parent Work Telephone Area Code Residential Parent Work Telephone Phone Number Residential Parent Social Security Number Residential Parent Date of Birth Residential Parent Race Residential Parent Employer Name Residential Parent Employment Begin Date Residential Parent Employer Street Address Residential Parent Employer City Residential Parent Employer State Residential Parent Employer Zip

Child Support Amount Spousal Support Amount Primary Insurance Name of Insured Primary Insurance Company Primary Insurance Street Address Primary Insurance City Primary Insurance State Primary Insurance Zip Primary Policy Number Primary Group Number Primary Plan Type Primary Begin Date Primary Individuals Covered Secondary Insurance Name of Insured Secondary Insurance Company Secondary Insurance Street Address Secondary Insurance City Secondary Insurance State Secondary Insurance Zip Secondary Policy Number Secondary Group Number Secondary Plan Type Secondary Begin Date Secondary Individuals Covered Child 1 Name Child 1 Gender Child 1 Race Child 1 Date of Birth Child 1 Social Security Number Child 2 Name Child 2 Gender Child 2 Race Child 2 Date of Birth Child 2 Social Security Number Child 3 Name Child 3 Gender Child 3 Race Child 3 Date of Birth Child 3 Social Security Number Child 4 Name Child 4 Gender Child 4 Race Child 4 Date of Birth Child 4 Social Security Number Child 5 Name Child 5 Gender Child 5 Race Child 5 Date of Birth Child 5 Social Security Number Child 6 Name Child 6 Gender Child 6 Race Child 6 Date of Birth Child 6 Social Security Number Submitting Attorney Submitting Attorney Telephone Area Code Submitting Attorney Telephone Phone Number