Application For Child Support Services
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1
2MISSISSIPPI
County Use Only
MDHS-CSE-675
Mississippi Department of Human Services
Case ID:
Revised 09-01-14
Division of Field Operations
CP Name:
☐ Full Services ($25)
☐ Parent Locate Only/No Charge
Application for Child Support Services
Date Requested:
Date Mailed/Given:
Date Received:
MDHS-CSE-614 Attached ☐ Yes ☐ No
I,
, am applying for support services on behalf of the following child(ren).
First
Middle
Maiden
Last
CHILD(REN) INFORMATION ON THIS CASE ONLY:
ST
Child’s Name
1
SSN:
DOB:
Sex:
Eth:
Cit:
Educ:
City & State of Birth:
Relationship to CP:
State of Conception:
nd
Child’s Name
2
SSN:
DOB:
Sex:
Eth:
Cit:
Educ:
City & State of Birth:
Relationship to CP:
State of Conception:
rd
Child’s Name
3
SSN:
DOB:
Sex:
Eth:
Cit:
Educ:
City & State of Birth:
Relationship to CP:
State of Conception:
th
Child’s Name
4
SSN:
DOB:
Sex:
Eth:
Cit:
Educ:
City & State of Birth:
Relationship to CP:
State of Conception:
Do the children have health insurance coverage:
CUSTODIAL PARENT (CP) INFORMATION
Are you the legal/biological parent: Yes ☐ No ☐
If no, complete other biological parent information below.
Social Security Number:
Birth Date:
Sex:
Eth:
Cit:
Educ:
Email Address:
Mailing Address:
Home Address:
Employer Name and Address:
Telephone Number: Home:
Work:
Cell:
Relationship to the noncustodial parent: Married ☐ Never Married ☐ Divorced ☐ Divorce Date:
Place of Divorce:
Separated ☐ Never Married-Paternity Established ☐ Other Relationship ☐ Explain:
Relationship to Child(ren): Not Related ☐ Other Relationship: ☐
NONCUSTODIAL PARENT (NCP) INFORMATION
Name:
Social Security Number:
Sex:
DOB:
Eth:
Cit:
Educ:
Ht:
Wt:
Hair:
Eyes:
Scars/Tattoos:
Alias:
City, County, and State of Birth:
Country, if not USA:
Email Address:
Mailing Address:
Home Address:
Telephone Numbers: Home:
Cell:
Employer Name, Address, and Phone Number:
Multiple Jobs:
Health Ins:
Children Covered:
Were you ever married to the other parent? Yes ☐ No ☐ Date of Marriage:
Divorced: Yes ☐ No ☐ Divorce Date:
/
/
/
/
Relationship to Child(ren): Parent, paternity not an issue ☐ Parent, paternity established by court order ☐ Alleged parent, paternity not established
☐ Excluded from paternity ☐. If paternity was established, tell how, such as: In Hospital Paternity ☐ Genetic Testing ☐ Court Order ☐
Stipulated Agreement ☐ Other ☐, specify:
Give date paternity established:
Comments:
OTHER BIOLOGICAL PARENT (OBP)/LEGAL PARENT INFORMATION
Name:
Social Security Number:
Sex:
DOB:
Eth:
Cit:
Educ:
Ht:
Wt:
Hair:
Eyes:
Scars/Tattoos:
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