Child Support Enforcement Account Information Sheet {DR-509-4}

CSE and COURT USE ONLY CHILD SUPPORT ENFORCEMENT ACCOUNT INFORMATION SHEET CSE: (513)732-7248 FAX: (513)732-7444 In order for Child Support Enforcement to set up a child support and/or medical insurance account, the following information must be completed. For spousal support only and no minor children, do not fill in any information after Defendant/Petitioner telephone number. JUDGE KATHLEEN RODENBERG DATE: _______________________ MAGISTRATE ___________________________ CASE NUMBER _________________________ PLAINTIFF/PETITIONER: __________________________________________ CURRENT ADDRESS: _________________________________________________________________________ PHONE #: _____________________ CELL PHONE #: ____________________ BIRTHDATE: ________________ SOCIAL SECURITY NUMBER: __________________ E MAIL ADDRESS: _______________________________ NAME AND ADDRESS OF EMPLOYER: ___________________________________________________________ __________________________________________ TELEPHONE NUMBER: _____________________________ DEFENDANT/PETITIONER: _________________________________________ CURRENT ADDRESS: _________________________________________________________________________ PHONE #: __________________ CELL PHONE #: __________________ BIRTH DATE: _____________________ SOCIAL SECURITY NUMBER: ______________________ E MAIL ADDRESS: ___________________________ NAME AND ADDRESS OF EMPLOYER: ___________________________________________________________ _________________________________________ TELEPHONE NUMBER: _______________________________ MINOR CHILD(REN): _________________________________ DOB: _____________ SSN: ____________________________________ _________________________________ DOB: _____________ SSN: ____________________________________ _________________________________ DOB: _____________ SSN: ____________________________________ _________________________________ DOB: _____________ SSN: ____________________________________ NAME OF PERSON ORDERED TO PROVIDE MEDICAL INSURANCE: ________________________________ INSURANCE COMPANY: Name: _____________________________________ Address: ___________________________________ ___________________________________________ City/State/Zip: _______________________________ Policy Number: ______________________________ CLAIMS SENT TO: (If different) _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ Group Number: __________________________________ Is insurance provided by Non Participating Participant (NPP)? (Example: Step Parent) ______Yes ______ No If Yes: Name of Party: __________________________________________________________________________ SS#: ________________________ DOB:_____________________ Employer Name & Address:______________________________________________________________________ DR-509-4 Rev 8/13 American LegalNet, Inc. www.FormsWorkFlow.com