Private Child Support Order Registration Form - Georgia Department Of Human Services
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1Georgia Department of Human Services
PRIVATE CHILD SUPPORT ORDER REGISTRATION FORM
(Used in private Non-IV-D collection and disbursement only child support cases)
Submit only this form with private child support order and Income Deduction Order as directed below.
(Pursuant to O.C.G.A. § 19-6-33.1)
Complete ALL fields – otherwise, the case cannot be registered and money cannot be disbursed.
Date Form Prepared:
Contact Person’s Name, Email & Telephone: (If attorney, please include bar #.)
Non-Custodial (Paying) Parent
Custodial (Receiving) Parent
Name: _________________________________________________
Name: ________________________________________________
Address: _______________________________________________
Address: ______________________________________________
_______________________________________________________
______________________________________________________
_______________________________________________________
______________________________________________________
DOB: _______________________________ Gender: [ ] M [ ] F
DOB: ______________________________ Gender: [ ] M [ ] F
SSN: __________________________ Race: __________________
SSN: _________________________ Race: __________________
Ethnicity:
[ ] Hispanic
[ ] Non-Hispanic
Ethnicity:
[ ] Hispanic
[ ] Non-Hispanic
Telephone #: ____________________________________________
Telephone #: ___________________________________________
Non-Custodial Parent’s Employer: ____________________________________________________________________________________
Address: _________________________________________________________________________________________________________
______________________________________________________________
Telephone #: _____________________________________
Court Order Information
County/State of Order: ___________________________________________
Civil Action Number: ______________________________
Date Order Signed by Judge: ______________________________________
Is this an order modifying child support? [ ] Yes [ ] No
Child Support Order Monthly
Amount: $_____________________________
First Due Date: ___________________________________
Date current child support will end per court order: _______________________________________________________________________
Amount of Family Support Registry (FSR) fee in order (O.C.G.A. §19-6-33.1(j)): _______________________________________________
Court ordered arrears amount: $____________________________________
As of Date: ______________________________________
Court ordered arrears Monthly
repayment amount: $______________________________________________________________________
Spousal Support Order Amount (if included in order): ______________________________________________
(
Notice : If no accompanying
child support payment is to be made, spousal support must be paid directly to the ex-spouse (rather than the FSR), pursuant to O.C.G.A. §19-6-33.1(e)(1).)
Children for Whom Child Support Is Ordered
Child’s full name
DOB
Gender
SSN
Race
Ethnicity (Hispanic
or Non-Hispanic)
__________________________
_____________ [ ] M [ ] F ___________________
_______________
_________________
__________________________
_____________ [ ] M [ ] F ___________________
_______________
_________________
__________________________
_____________ [ ] M [ ] F ___________________
_______________
_________________
___________________________ _____________ [ ] M [ ] F ___________________
_______________
_________________
Mail OR Fax this completed form along with a copy of the Child Support Order, and Income Deduction Order that was signed
by a judge. Please DO NOT Mail AND Fax the documents as that will delay case registration & distribution of child support.
Mail to:
Family Support Registry
P. O. Box 1800
Carrollton, Georgia 30112-1800
OR---Fax documents to: 770-836-2701 (If you fax the documents, do not also send them by mail.)
Georgia Family Support Registry, Non-IV-D Case Registration Form
Last Update: August 23, 2012, v1.1
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