Free 51802 (8-04).FH11 - Indiana

IV-D APPLICANT INFORMATION
State Form 51802 (8-04) / CSB 0007

* The request for your Social Security number is MANDATORY and this form cannot be processed without it. The information contained on this completed form is CONFIDENTIAL according to 45 CFR 302.21 and 45 CFR 303.70.

Name of IV-D applicant Address of applicant (number and street, city, state, ZIP code)

Maiden name (if applicable)

Telephone number

(
Other address of applicant (number and street, city, state, ZIP code) Telephone number

)

( NAME(S) OF CHILD(REN)

) DATE OF BIRTH (month, day, year)

Have you ever been to a Prosecutors office to file a paternity case for the child(ren)? (check one)

Yes
If so, where?

No

OTHER PARENT INFORMATION: (Complete for each parent for case)
Full name of parent Last know address (number and street, city, state, ZIP code) Alias Date (month, day, year)

Last known employer Address of employer (number and street, city, state, ZIP code)

Date (month, day, year)

Age

Date of birth (month, day, year)

City and state of birth

PHYSICAL DESCRIPTION:
Race Other: Name of non-custodial parents father Address of non-custodial parents father (number and street, city, state, ZIP code) Maiden name of non-custodial parents mother Address of non-custodial parents mother (number and street, city, state, ZIP code) Sex Height Hair Eyes Weight

Non-custodial parents Social Security number *

MILITARY BACKGROUND:
Branch Date (month, day, year) Rank

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OTHER PARENT INFORMATION: (continued) (Complete for each parent for case)
Arrest record City and state Date (month, day, year)

AUTOMOBILE INFORMATION:
Make Is non-custodial parent an Indiana resident? Model License number

Does non-custodial parent receive government benefits?

Yes

No

Yes

No

Friends or relatives with whom the non-custodial parent would have contact:

Is non-custodial parent a member of an organization?

Yes

No
City and state City and state Cause number: Date started (month, city, state) Date calculated (month, city, state) Paid to: By:

MARITAL INFORMATION:
Date married (month, day, year) Date divorced (month, day, year) Name of court Support order amount:

$
Amount of delinquency:

$
Date of last payment (month, day, year) Date of last legal action (month, day, year) Describe legal action taken:

Name of recipients previous legal counsel

Name of non-custodial parents previous legal counsel

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