Support Payment Registration

PORTAGE COUNTY CHILD SUPPORT ENFORCEMENT AGENCY SUPPORT PAYMENT REGISTRATION FORM 209 S. CHESTNUT STREET, 2ND FLOOR, ROOM 203 RAVENNA, OH 44266 DATE: CASE NO: 1. PAYOR INFORMATION (one making support payments) Name: Address: Number Street City Social Security No: State Zip Telephone (home): Your Atty's Name: Employer's Name: Employer's Address: Number Street (cell): Phone: City State Zip Are you currently paying another agency? If yes, please state who: Driver's License No: Yes No Case No: Date of Birth: 2. PAYEE INFORMATION (one receiving payments) Name: Social Security No: Address: Number Street City State Zip Telephone (home): Are you on Welfare?: Your Atty's Name: Driver's License No: (cell): Yes No Phone: Date of Birth: 3. HEALTH INSURANCE INFORMATION Who is ordered to provide health insurance coverage? Insurance Company Name: Name of Health Plan: Address: Number Street City State Payor? Payee? Zip Customer Service Phone Number: Group Number: 4. Child's Name I.D. Number: Date of Birth Social Security No. I/we hereby certify that the above information is correct to the best of my/our knowledge. _________________________________________ *You may write any additional Payor's Signature information on the back of this form, if you wish. _________________________________________ Payee's Signature X/Appendices[Index]/3 - CSEA Reg American LegalNet, Inc. www.FormsWorkFlow.com