STATE OF WYOMING COUNTY OF ________
) ) ss. )
IN THE DISTRICT COURT ___________ JUDICIAL DISTRICT Civil Action No. _____________
____________________, Petitioner, vs. _____________________, Respondent.
) ) ) ) ) ) ) ) )
CONFIDENTIAL
CONFIDENTIAL STATEMENT FOR CHILD SUPPORT ORDER
The following information shall remain confidential and subject to inspection by persons other than the parties, their attorneys or the department of family services to the extent necessary to enforce the Child Support Enforcement Act and the Uniform Interstate Family Support Act only by court order and contains the: 1. The name and social security number of each parent: Name of Petitioner: Petitioner's Social Security Number: Name of Respondent: Respondent's Social Security Number: 2. The name and social security number of the child or children for whom child
support has been ordered: Child's Name: Child's Social Security Number: Child's Name: Child's Social Security Number: Child's Name: Child's Social Security Number:
CSMod 18 Confidential Statement for Child Support Order Revised July 2006 Page 1 of 2
Child's Name: Child's Social Security Number: DATED this _____ day of ______________________, 2_____. IN WITNESS WHEREOF, we have hereunto set our hands the day and year first above written. Signature Printed Name: Address: Phone Number:
CERTIFICATE OF SERVICE I certify that on (date) the original of this document
was filed with the Clerk of District Court; and, a true and accurate copy of this document was served on the other party by OR Hand Delivery OR Faxed to this number
by placing it in the United States mail, postage pre-paid, and
addressed to the following:
TO: ______________________________________ ______________________________________ ______________________________________
(Your signature)
Print name
CSMod 18 Confidential Statement for Child Support Order Revised July 2006 Page 2 of 2