Elkhart County Child Support

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PATERNITY QUESTIONNAIRE
(COMPLETE ONE PER CHILD)

Case Number
ENROLLEE INFORMATION
Full Legal Name:
Maiden Name/Aliases:
SSN# (Last 4 Digits)
Date of Birth: (mm-dd-yyyy)
Place of Birth:
Race:
Residence Address:
Mailing Address:
Contact Phone:
Cell Phone:
Work Phone:
Email:
Employer Name & Address:
Gross Weekly or Monthly Income (TANF; Food Stamps; Other) )
Have you ever married?
Present Marital Status:
Are there any Protective Orders or safety concerns for you and/or your child?
Protective Order Case No:
County
State
CHILD'S INFORMATION
Full Legal Name:
Date of Birth: (mm-dd-yyyy)
SSN# (Last 4 Digits)
Place of Birth:
City
Country:
State:
Do you want to have custody of the child?
If no, who will have custody?
Estimated weekly expenses for child (food, clothes, diapers, day care, etc.):
Are there any extraordinary medical/educational expenses for the child?
If yes, explain:
INFORMATION REGARDING THE PATERNITY OF THE CHILD
Name every individual with whom you had sexual relations within the twelve (12) months prior to the child's date of birth:
Name
Who is the individual most likely to be the father of this child?
Were you ever married to this individual?
Has he admitted to being the father of the child?
Where, when, and to whom did he make this admission?
Has he given you money or gifts for the child or during your pregnancy?
If yes, please explain?
Do you object to this individual having visitation with the child?
If yes, what visitation would be acceptable?
Do you object to the last name of the child being changed?
INFORMATION REGARDING THE OTHER PARENT
Full Legal Name:
Maiden Name/Aliases:
SSN:
Date of Birth: (mm-dd-yyyy)
Place of Birth:
Race:
Residence Address:
Mailing Address:
Contact Phone:
Cell Phone:
Work Phone:
Email:
Employer Name:
Employer Address: (Street, City & State)
What is the Other Parent's current income (if known)?
Does the Other Parent have other child support obligations?
If yes, to whom does the Other Parent pay support?
If known, what is the Other Parent's existing support obligation?
per
Other Parent's Military Experience:
Branch:
Other Parent's Arrest Record:
Date: (mm-dd-yyyy)
Offense: (City/State)
Other Parent's Father's Name and Address:
Other Parent's Mother's Name and Address:
Friends or relative's names and contact information with whom the Other Parent would have contact:
Organizations to which the Other Parent belongs:
Automobile owned by Other Parent:(Year, Make, Model & License Plate No.)
Does the Other Parent receive any type of government benefits?
If yes, what type of benefits and how much does the Other Parent receive each month?
Please add any additional information about the Other Parent which you believe may be helpful:
INFORMATION REGARDING CONCEPTION
When and where did you meet the person believed to be the father of your child? (Date, City & State)
Did you and he live together?
If yes, when and where:
When and where did you first have sexual intercourse with the presumed father? (Date, City & State)
When and where did you last have sexual intercourse with the presumed father? (Date, City & State)
What was your due date? (mm-dd-yyyy)
Based on the due date, what was the time and place of conception? (Date, City & State)
Did you tell the presumed father that you were pregnant?
If yes, when and where, and what was his reaction?
Did the presumed father tell anyone else about your pregnancy?
If yes, whom did he tell?
Did the presumed father acknowledge in writing that he is the father of the child?
If yes, when and where did he acknowledge that he is the father of the child?
During the month before conception, the month of conception, the month after conception, did you have sexual intercourse with anyone besides the presumed father?
If yes, with whom and how often?
Were you and the presumed father married to each other during the time of conception?
If yes, are you still married?
If no, how and when did the marriage end? (divorce, annulment, etc.)
Is the presumed father presently married to someone else or was he married to someone else at the time of conception and/or birth of your child?
If yes, name his spouse and explain when he was married?
Were you married to someone else other than the presumed father at the time of conception?
If yes, name that individual and explain when you were married:
Did you and the presumed father attempt to marry each other after the birth of the child?
If yes, please explain
Did the child live with the presumed father at any time?
If yes, please explain
Has any member of his family (mother, sister, etc.) seen or asked to see the child?
Please add any additional information about the conception of the child which you believe may be helpful in establishing paternity:
INFORMATION ABOUT YOU
Do you presently receive court-ordered support payments for any of your children?
If yes, for which child(ren) and from whom do you receive these payments and how much is court-ordered support:
Have you previously pursued legal action to establish paternity for any of your child(ren)?
If yes, against whom and what was the result? (City & State)
Please add any additional information or comments which you believe may be helpful:
CERTIFICATION

I understand that the information I have provided is confidential and is intended for the use of the Elkhart County Prosecuting Attorney in pursuing legal action on behalf of my child. I also understand that further action is completely within the discretion of the Prosecuting Attorney.

I further understand that I must cooperate with the Prosecuting Attorney in establishing the paternity of my child. I realize that cooperation includes answering questions fully and truthfully about possible fathers when asked, attending court proceedings when required, and submitting to DNA testing when ordered by the Court.

I further realize that my failure to provide complete and truthful answers in this questionnaire may result in perjury charges being filed against me and/or that I may be removed from the Department of Child and Services or the Title IV-D Program for failing to cooperate with the Prosecuting Attorney.

Signature
Date (mm-dd-yyyy)
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Office of the Prosecuting Attorney, 301 S. Main St., Suite 100, Elkhart, IN 46516 | P: (574) 522-3074 | F: (574) 522-4965
www.elkhartcountyprosecutor.com
     


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