Indiana > Local County > Elkhart
UIFSA Questionnaire - Indiana
| UIFSA Questionnaire Form. This is a Indiana form and can be used in Elkhart Local County . |
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UIFSA QUESTIONNAIRE IN ORDER TO FILE A UIFSA PETITION, WE MUST HAVE THE FOLLOWING INFORMATION. THESE QUESTIONS MUST BE ANSWERED FULLY AND COMPLETELY. IF YOU ARE UNABLE TO ANSWER A SPECIFIC QUESTION, YOU MUST STATE WHY THAT QUESTION CANNOT BE ANSWERED. THIS INFORMATION WILL BE USED FOR PURPOSES OF THE UIFSA ACTION ONLY. DATE: INFORMATION ABOUT YOURSELF: YOU R NAME AND ADDRESS (Including City and State) DATE OF BIRTH: PHYSICAL DESCRIPTION: HEIGHT: HAIR: EYES: AGE: OCCUPATION: RELATIONSHIP TO CHILD(REN): CURRENT MARRITAL STATUS: RELATIONSHIP TO ABSENT PARENT: IF YOU ARE NOT THE NATURAL MOTHER OR FATHER OF THE CHILD(REN) GIVE THE NAME(S) AND ADDRESS OF THE NATURAL PARENT(S): LIST ALL PERSONS LIVING IN YOUR HOUSEHOLD: NAME: DOB: RELATIONSHIP: SOURCE OF INCOME: S.S.# WEIGHT: HM. PHONE: WK. PHONE: RACE: American LegalNet, Inc. www.USCourtForms.com INFORMATION ABOUT THE NON-CUSTODIAL PARENT: NAME AND ADDRESS (Including City and State): MAIDEN, ALIAS OR NICK NAME: PLACE OF BIRTH: AGE: RACE: SCARS: HM. PHONE: EMPLOYERS NAME AND ADDRESS: OCCUPATION, TRADE OR PROFESSION: ESTIMATE GROSS MONTHLY INCOME: OTHER INCOME: REAL OR PERSONAL PROPERTY: PRESENT MARITAL STATUS (IF KNOWN): CURRENT SPOUSE/PARTNER EMPLOYED?: ESTIMATED GROSS MONTHLY EARNINGS: NAME AND ADDRESS OF CURRENT SPOUSE/PARTNER'S EMPLOYER: IS THE NON-CUSTODIAL PARENT RESPONSIBLE FOR DEPENDENTS THAT ARE NOT LIVING IN YOUR HOUSEHOLD? NAME: D.O.B. RELATIONSHIP LIVING WITH D.O.B.: HEIGHT: S.S.# WEIGHT: TATOOS: WK. PHONE: HAIR: EYES: ATTACH PHOTO: American LegalNet, Inc. www.USCourtForms.com INFORMATION ABOUT THE CHILD(REN): LIST CHILD(REN) OF NON-CUSTODIAL PARENT ONLY. NAME: AGE: SEX: D.O.B. S.S.# PATERNITY ESTABLISHED [ ] YES [ ] YES [ ] YES INFORMATION ABOUT MARITAL STATUS: WERE YOU MARRIED TO THE NON-CUSTODIAL PARENT? IF SO, DATE: STATE, CITY, COUNTRY: DATE DIVORCE FINALIZED: [ ] NO [ ] NO [ ] NO SUPPORT ORDER LIVING WITH PETITIONER ARE YOU NOW DIVORCED? NAME AND ADDRESS OF COURT: DATE OF COURT ORDER: WAS PATERNITY ESTABLISHED: AMOUNT OF SUPPORT: IN WHICH STATE WAS PATERNITY ESTABLISHED: HOW MANY TIMES HAVE YOU BEEN MARRIED: NAME: DATE: LOCATION: American LegalNet, Inc. www.USCourtForms.com NAME OF SPOUSE/PARTNER: YOUR GROSS WEEKLY INCOME: MEDICAL INSURANCE: ARE THE DEPENDENTS FOR WHOME SUPPORT IS SOUGHT PRESENTLY COVERED BY MEDICAL INSURANCE: IS THE NON-CUSTODIAL PARENT ORDERED TO PROVIDE MEDICAL INSURANCE: WHO PROVIDES MEDICAL INSURANCE FOR THE CHILD(REN) AT THIS TIME: THE NAME OF THE INSURANCE COMPANY: POLICY NUMBER: INSURANCE COMPANY OF CUSTODIAN'S EMPLOYER: COST PER MONTH: WERE THE CHILDREN EVER COVERED BY MEDICAL INSURANCE PROVIDED BY THE NON-CUSTODIAL'S EMPLOYER? DO ANY OF THE NON-CUSTODIAL'S CHILDREN HAVE SPECIAL NEEDS OR EXTRAORDINARY MEDICAL EXPENSES NOT COVERED BY INSURANCE? IF SO, PLEASE EXPLAIN: CRIMINAL INFORMATION: DOES THE NON-CUSTODIAL PARENT HAVE A TRAFFIC OR CRIMINAL RECORD: VIOLATION: LOCATION: DATE: INCARCERATED: SUPPORT ORDER AND PAYMENT INFORMATION: IS THE ABSENT PARENT PAYING CURRENT CHILD SUPPORT: AMOUNT OF THE ORDER: WHEN DID THE RESPONDENT MAKE THE LAST SUPPORT/ARREARAGE PAYMENT AND HOW MUCH WAS THE PAYMENT? HAS THE RESPONDENT EVER PAID CHILD SUPPORT DIRECTLY TO YOU? IF SO, HOW MUCH, AND THE DATE PAYMENTS WERE MADE: DO YOU HAVE RECEIPTS FOR ANY PAYMENTS MADE DIRECTLY TO YOU? IF YES, PLEASE ATTACH. American LegalNet, Inc. www.USCourtForms.com FINANCIAL INFORMATION: EMPLOYED: [ ] YES PUBLIC ASSISTANCE: MONTHLY AFDC PAYMENTS MONTHLY FOOD STAMP BENEFITS OTHER: EMPLOYMENT INCOME: [ ] GROSS [ ] NET (ATTACH 3 OF YOUR MOST RECENT PAY STUBS FROM EACH CURRENT EMPLOYER) DEDUCTIONS: INCOME TAX WITHHOLDING (FEDERAL + STATE + LOCAL) FICA (SOCIAL SECURITY) MANDATORY UNION DUES MANDATORY RETIREMENT MEDICAL INSURANCE PREMIUMS COVERAGE THE DEPENDENTS OTHER: OTHER EARNINGS: MONTHLY BUSINESS INCOME EXPLAIN: MONTHLY EXPENSES: CHILD CARE: PROVIDER: FREQUENCY: [ ] NO IF YES, PLEASE LIST OCCUPATION: AMOUNT: UNINSURED EXTRAORDINARY MEDICAL (ATTACH DESCRIPTION & DOCUMENTATION) OTHER SUPPORT PAYMENTS, ACTUALLY MADE EDUCATION (RESPONDENT'S CHILDREN) HOUSING AND UTILITIES FOOD & HOUSEHOLD SUPPLIES OTHER EARNINGS: MONTHLY CHILD SUPPORT: MONTHLY ALIMONY OR SPOUSAL SUPPORT INCOME: GOVERNMENT PAYMENTS: EXPLAIN: MONTHLY PENSION BENEFITS: SOURCE: UNEMPLOYMENT COMPENSATION: SOURCE AND DURATION: American LegalNet, Inc. www.USCourtForms.com OTHER MONTHLY INCOME: SOURCE AND EXPLAIN: DEPENDENT'S INCOME: [ ] GROSS [ ] NET (ATTACH THE THREE MOST RECENT STUBS FROM EACH CURRENT EMPLOYER) PROVIDE ANY ADDITIONAL INFORMATION IMPACTING INCOME, PARTICIPATION IN JOBS PROGRAM MONTHLY EXPENSES (CONTINUED) TRANSPORTATION: PERSONAL EDUCATION EXPENSES: OTHER UNINSURED HEALTH RELATED EXPENSES: CLOTHING: INSURANCE PREMIUMS: ENTERTAINMENT: ALL OTHER EXPENSES AND PAYMENTS: American LegalNet, Inc. www.USCourtForms.com
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