Texas > Local County > Harris
Child Support Information Sheet - Texas
| Child Support Information Sheet Form. This is a Texas form and can be used in Harris Local County . |
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Child Support Information Sheet Cause Number _____________________________________ AG Case Number (if applicable)________________________ Order Status: (circle one) Temporary Final Should Income Withholding be issued? Yes No OBLIGOR (PAYOR) INFORMATION Last Name: ______________________________________________ First Name: ______________________________________________ Middle Name: __________________________________ Title: _____ Home Address: ______________________________ Apt/Suite_____ City: _____________________ State: _________ Zip Code: _______ Soc. Sec. No: __________________ DOB: __________ Sex: M / F Phone: (H)____________________ (W)_______________________ Drivers License No: ________________________ ST: __________ County of Residence: ______________________________________ Relationship to Child(ren): __________________________________ Employer: ______________________________________________ Address: ________________________________________________ City: _____________________ State: _________ Zip Code: _______ Court Number _____________ Previously Issued? Modified Order? Existing Account? Yes Yes Yes No No No OBLIGEE (PAYEE) INFORMATION Last Name: ______________________________________________ First Name: ______________________________________________ Middle Name: _________________________________ Title: _____ Home Address: ____________________________Apt/Suite_______ City: ___________________State: _________ Zip Code: _________ Soc. Sec. No: ________________ DOB: ____________ Sex: M / F Phone: (H) ______________________(W)_____________________ Drivers License No: ________________________ ST: __________ County of Residence: ______________________________________ Relationship to Child(ren): _________________________________ Employer: ______________________________________________ Address: ________________________________________________ City: ____________________ State: _________ Zip Code: _______ Obligor Signature: _________________________________ Date: _______________, 20_____ CHILD'S NAME (First, Middle, Last) Obligee Signature: _________________________________ Date: _______________, 20_____ DATE OF BIRTH (MM/DD/YYYY) SEX M/F M/F M/F M/F M/F M/F SOCIAL SECURITY NUMBER OBLIGATION SUMMARY Order Type: (circle one) Divorce Paternity SAPCR Enforcement Modification Date Order Submitted/Signed _______ Regular Child Support: $___________________ (monthly, semi-monthly, biweekly, weekly) Begin Date: _______________, 20____ CIRCLE ONE Cash Medical Support: $___________________ (monthly, semi-monthly, biweekly, weekly) Begin Date: ______________, 20_____ CIRCLE ONE Medical Insurance: Obligor provides Obligee provides CIRCLE ONE Both Responsible Not addressed Cash Spousal Support: $___________________ (monthly, semi-monthly, biweekly, weekly) Begin Date: ______________, 20_____ CIRCLE ONE * Obligor Attorney Phone *Obligee Attorney Phone *Attorney/Obligor/Obligee may be contacted if questions occur during account establishment. Form prepared by: _________________________________ Phone: ________________________ Date: __________, 20______ HCCSIS11927 American LegalNet, Inc. www.FormsWorkFlow.com
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