Fill and Sign the Intent of This Form is to Provide a Degree of Privacy to the Parties and to Help Deter and

1. The intent of this form is to provide a degree of privacy to the parties, and to help deter andprevent identity theft. 2. The form must be used in all Domestic Relations cases in which minor children are involved. The form must be filed with the Domestic Relations Cover sheet at initial filing. Additionally, acopy of this form must be filed with the Office of Child Support Enforcement (P.O. Box 8128,Little Rock, AR 72203). The parties in each case should update and re-file this form with theCircuit Clerk and the Office of Child Support Enforcement whenever either parties’ informationchanges. 3. The parties or their attorney should provide the information available to the clerk at the initialfiling. 4. If any of the designated information is unavailable, please so indicate by marking theappropriate field (s) with N/A (not available). With this documentation, the clerk must accept apartially completed form. 5. The clerk will not file this form in the case file. It should be maintained in a separate file,folder or book. Access to this form is limited to the Office of Child Support Enforcement,attorneys of record, parties appearing Pro Se, or persons authorized in writing by the circuit court. 6. The custodial parent or custodian of the children should be entered in the top section of theform. If custody has not been determined, the person who has physical custody of the childrenshould be entered in the top section. If the parties are dividing the care of the child, enter one inthis section and one in the non-custodial section. 7. Enter all children with their dates of birth and Social Security numbers in the bottom sectionof the form. 8. If there are more than four children, make a second copy of this sheet to add the remainingchildren. 9. The OCSE Case number is to be used only by the Office of Child Support Enforcement. 10. The preparer’s line should be completed by the person providing the information. Pleasetype or print the name of the preparer. 11. The instructions are based upon Act 1877 of 2005 which amends Arkansas Code § 9-14-205. 12. The clerk if reporting by paper form should send a copy of the Domestic Relations Coversheet and a copy of the Confidential Data sheet to the Administrative Office of the Courts. Forclerks reporting by floppy diskette, please contact your AOC regional auditor for instructions toreport by email. If the clerk provides a copy of the DR Cover sheet or court order to OCSE, aConfidential Data sheet must be provided also. [revised 09-09-2005]