Elkhart County Child Support

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Uniform Interstate Support Act (UIFSA) Questionnaire

IN ORDER TO FILE A UIFSA PETITION, WE MUST HAVE THE FOLLOWING INFORMATION. THESE QUESTIONS MUST BE ANSWERED FULLY AND COMPLETELY. IF YOU ARE UNABLE TO ANSWER A SPECIFIC QUESTION, YOU MUST STATE WHY THAT QUESTION CANNOT BE ANSWERED. T M S INFORMATION WILL BE USED FOR PURPOSES OF THE UIFSA ACTION ONLY.
Date (mm-dd-yyyy)
INFORMATION ABOUT YOURSELF:
Your Name:
Address (Street, City & State)
Date of Birth (mm-dd-yyyy)
Race
Height
Weight
Hair
Eyes
Contact Phone
Cell Phone
Work Phone
Email
Occupation
Relationship to child(ren)
Other (specify)
Current Marital Status
Relationship to Other Parent
What Child(ren) is this Questionnaire for?
Name
DOB (mm-dd-yyyy)
Who has physical custody?
Are there any Protective Orders or any safety concerns for you and/or the child(ren)?
Protective Order Case No.
City
State
If you are not the natural mother or father of the child(ren), provide the name(s) and addresses of the natural parent(s):
List all persons living in your household:
Name
DOB (mm-dd-yyyy)
Relationship
Source of Income
INFORMATION ABOUT THE OTHER PARENT:
Name
Address or Last Known address (Street, City& State)
Maiden, Alias, or Nick Name(s)
Place of Birth
Date of Birth (mm-dd-yyyy)
Age
Soc. Sec#
Physical description:
Race
Height
Weight
Hair
Eyes
Scars
Tattoos
Contact Phone
Cell Phone
Work Phone
Email
Employer Name
Address (Street, City& State)
Occupation, trade or profession
Estimate Gross Monthly Income
Other Income
Real or personal property
Present marital status (if known)
ls current spouse/partner employed?
Estimated Gross Monthly Income
Name and address of current spouse/partner's employer
Is the Other Parent responsible for dependents that are not living in your household?
Name
DOB (mm-dd-yyyy)
Relationship
Living With
LIST INFORMATION ABOUT THE CHILD(REN) OF THE OTHER PARENT:
Name
DOB (mm-dd-yyyy)
Age
Sex
SSN
Paternity Established?
Support Order
Living with Petitioner
INFORMATION ABOUT MARITAL STATUS:
Were you married to the Other Parent?
If yes, date of marriage (mm-dd-yyyy)
City, State & Country
Are you divorced?
Date divorced finalized (mm-dd-yyyy)
Name, address, county, city and state of court where divorce is filed
Date of Court Order (mm-dd-yyyy)
Amount of Support
Was paternity established?
If yes, name the city, county and state were paternity was established
How many times have you been married?
Name
Date (mm-dd-yyyy)
Location
Name of spouse/partner
Your Gross Weekly Income
MEDICAL INSURANCE:
Are the dependents for whom support is sought presently covered by medical insurance?
ls the Other Parent ordered to provide medical insurance?
Who provides medical insurance for the child(ren) at this time?
Provide the name of the Insurance Company
Policy Number
Insurance Company of custodian's employer
Cost per month
Were the children every covered by medical insurance provided by the Other Parent's employer?
Do any of the Other Parent's children have special needs or extraordinary medical expenses not covered by insurance?
CRIMINAL INFORMATION:
Does the Other Parent have a traffic or criminal record?
Violation
Date (mm-dd-yyyy)
Location
Place of incarceration
SUPPORT ORDER AND PAYMENT INFORMATION:
ls the Other Parent paying current child support
Amount of the Order
When did the Other Parent make the last support/arrearage payment? (mm-dd-yyyy)
How much was the payment?
Has the Other Parent ever paid child support directly to you?
If yes, how much
Dates payments were made
Do you have receipts for any payments made directly to you?
FINANCIAL INFORMATION:
Are you currently employed?
If yes, please list occupation
Public Assistance
$
Monthly AFDC Payments
$
Monthly Food Stamp Benefits $
Other
$
Employment Income
$
Deductions
$
Income Tax Withholding (Federal +State+ Local)
$
FICA (Social Security)
$
Mandatory Union Dues
$
Mandatory Retirement
$
Medical Insurance Premiums Coverage
$
The Dependents $
Other $
Other Earnings:
Monthly Business Income
Explain
Monthly Expenses:
Child Care $
Provider
Frequency
$
Uninsured extraordinary medical (attach description & documentation) $
Other support payments, actually made $
Education (Other Parent's children)
Housing and Utilities $
Food and Household Supplies $
Other Earnings:
Monthly Child Support $
Monthly Alimony or Spousal Support Income $
Government Payments:
Explain
$
Monthly Pension Benefits
Source
$
Unemployment Compensation
Source and duration
$
Other Monthly Income:
Source and explain
$
Dependent's income:
$
Provide any additional information that may impact your income such as participation in a jobs program:
Monthly Expenses:
Transportation
$
Personal Education Expenses
$
Other Uninsured Health Related Expenses
$
Clothing
$
Insurance Premiums
$
Entertainment
$
All other Expenses and Payments
$

Please attach the following documents:
1. Photo (Other Parent)
2. Payment Receipts
3. 3 Paystubs of Current Employer (Other Parent)
4. 3 Paystubs of Current Employer (Dependent)

Attach Document (PDF, JPG, PNG, GIF, TIFF Only)


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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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