Fill and Sign the Registration Statement Form

REGISTRATION STATEMENT Responding IV-D Case No. _______________________ Initiating IV-D Case No. ________________________ Responding Docket No. __________________________ Initiating Docket No. ___________________________ I. Case Summary (Background of this Matter: Court / Administrative Actions) Date of Support Order State and County Issuing Order Tribunal Case No. Support Amount/Frequency Date of Last Payment Amount of Arrears Period of Computation $ $ ______ thru ______ Date Date II. Mother Information [ ] Obligor [ ] Obligee Full Name and Aliases Address (Street, City, State, Zip) Employer (Name, Street, City, State, Zip) (First, Middle, Last) SSN: III. Father Information [ ] Obligor [ ] Obligee Full Name and Aliases Address (Street, City, State, Zip) Employer (Name, Street, City, State, Zip) (First, Middle, Last) SSN: IV. Caretaker (If Not a Parent) Relationship to Child(ren) _______________________________________________________________________________________________ Full Name and Aliases Address (Street, City, State, Zip) (First, Middle, Last) SSN: V. Additional Case Information This order is registered in the following states: Description and location of any property not exempt from execution: - 1 - Other: VI. Verification / Certification Under penalties of perjury, all information and facts concerning the arrearage accrued under this order are true to the best of my knowledge and belief. ____________________________ ____________________________________________________________ Date [ ] Party seeking Registration [ ] Records Custodian __________________________________ _____________________________________________________ Sworn to and Signed Before Me This Notary Public, Court/Agency Official and Title Commission Expires Date, County/State Registration Statement OMB No. _______ Page 1 of 1 - 2 -