Fill and Sign the Statement Child Support Form

STATE OF WYOMING ) IN THE DISTRICT COURT ) ss COUNTY OF ________________ ) _______________ JUDICIAL DISTRICT Petitioner:___________________________,) Civil Action Case No. __________ (Print name of person filing) ) ) vs. ) CONFIDENTIAL ) Respondent:_________________________ .) (Print name of other party) CONFIDENTIAL STATEMENT FOR CHILD SUPPORT ORDER Pursuant to the requirements of Wyo. Stat. §20-2-309(b), the following information is confidential and may only be accessed by 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. Other persons or entities may examine this statement only if permitted by court order. 1. Information for each parent: Name of Petitioner : Address: Petitioner’s Social Security Number: Date of Birth: Place of Birth: Petitioner’s Employer: Employer’s Address: Name of Respondent : Address: Respondent’s Social Security Number: Date of Birth: Place of Birth: Respondent’s Employer: Employer’s Address: Confidential Statement for Child Support Order July 2014 Page 1 of 3 2. Information for each child for whom child support has been ordered in this case: Child’s Name : Address: Child’s Social Security Number: Date of Birth: Place of Birth: Child’s Name : Address: Child’s Social Security Number: Date of Birth: Place of Birth: Child’s Name : Address: Child’s Social Security Number: Date of Birth: Place of Birth: Child’s Name : Address: Child’s Social Security Number: Date of Birth: Place of Birth: Add additional sheets of paper if needed to provide information for more children. DATED this _____ day of ______________________, 20_____. Signature Printed Name: Address: Phone Number: Confidential Statement for Child Support Order July 2014 Page 2 of 3 Confidential Statement for Child Support Order July 2014 Page 3 of 3