Child Support - Cabarrus County

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PART FOUR: NONCUSTODIAL PARENT (CONT.)NONCUSTODIAL PARENT MILITARY AND ARREST RECORDMilitary Service? Yes No If yes, what branch? RankActive Duty Reserve Retired Separated AWOL UnknownLast known duty station Service Start Date Service End DateCurrently in prison/jail? Yes NoPrison/Jail Name:Prior Arrest Record: Yes No If yes, when and where?Offense Convicted? Yes No Conviction Type Felony Misdemeanor DateIs noncustodial parent currently on parole/probation? Yes No If yes, where?Name of Parole/Probation Officer:4PART FIVE: SUPPORT ORDER INFORMATIONDo you get support? Yes No If yes, do you have a Court Order or Voluntary Agreement to support? (check one)Please attach a copy of your court order or agreement to support.Type(s) of Support Child Support Medical Support Spousal/Alimony Support (check all that apply)How is support paid? (Check one) Centralized Collections Direct to you To(landlord, daycare center, etc.)Court docket number Order Effective Date County StateAmount Ordered $ per Amount of past due support $Children included in the order agreementUse this space to tell us any additional information that you think will help us get support for you.
CABARRUS COUNTY CHILD SUPPORTCLIENT QUESTIONNAIREDATE:CLIENT NAME:____________________________________________________________1) MARK THE SERVICES YOU ARE REQUESTING__________________________________________CURRENT SUPPORTMEDICAL INSURANCEPRIOR MAINTENANCE (BACK SUPPORT)Note: Receipts are required for Prior Maintenance2) DAY CARE / CHILDCARE____________ DO YOU HAVE DAY CARE / CHILD CARE EXPENSES ?IF YOU ANSWERED “YES”, WHAT IS THE NAME OF YOUR PROVIDERAND THE MONTHLY COST FOR EACH CHILD ?Note: Receipts are required for verification____________________________________________________________________________________________________________________3) MEDICAL INSURANCE____________________________ARE THE CHILDREN COVERED BY PRIVATE MEDICAL INSURANCE THAT IS NOTMEDICAID OR MEDICAID HEALTH CHOICE ?IF YOU ANSWERED “YES” ABOVE, WHO CURRENTLY PROVIDES THE MEDICALINSURANCE FOR THE CHILD(REN) ?4) RESPONSIBILITY FOR OTHER NATURAL CHILDREN______________ ARE YOU RESPONSIBLE FOR ANY OTHER BIOLOGICAL CHILDREN UNDER 18YEARS OF AGE (AND IN SCHOOL) IN YOUR HOME ?LIST THEIR NAMES AND AGES:__________________________________________________________________________________________________________________________________ DOES THE OTHER PARENT LIVE WITH YOU IN YOUR HOME ?______________ IF YOU ANSWERED “YES” ABOVE, WHAT IS THEIR MONTHLY GROSS INCOME ?______________ DOES THE OTHER PARENT HAVE ANY OTHER BIOLOGICAL CHILDREN ?LIST THEIR NAMES AND AGES:____________________________________________________________________________________________________________________Revised 3/2009 apt
Page 1 and 2: CABARRUS COUNTYDepartment of Social
Page 3 and 4: For Office Use OnlyIVD Number Locat
Page 5: CHILD SUPPORT APPLICATION SUPPLEMEN

Child Support - Cabarrus County

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