Elkhart County Child Support
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TITLE IV-D Status Request Form
Due to the volume of cases handled by the Elkhart County Child Support Division,
EVERYONE
must complete this questionnaire. You will receive a response within 7-10 business days. We thank you for your cooperation.
Date
(mm-dd-yyyy)
YOUR INFORMATION:
Are you? (check one):
Paying Support
Receiving Support
Name
SS# (Last 4 Digits)
Phone
Email
Address
City
State
Zip
(check box if this is a change of address)
Yes
Employer Name
Address
City
State
Zip
Do you have an attorney? (check one):
YES
NO
If yes, name of attorney:
INFORMATION OF OTHER PARTY:
Name
SS# (Last 4 Digits)
Phone
Email
Address
City
State
Zip
(check box if this is a change of address)
Yes
Employer Name
Address
City
State
Zip
LIST ALL CHILDREN INVOLVED IN THIS CASE:
Add section
Child Name
Date Of Birth:
(mm-dd-yyyy)
Remove
Reason for Request
TITLE IV-D CHILD SUPPORT MODIFICATION HEARING REQUEST
ALL questions MUST be answered or a child support modification hearing WILL NOT be set or may be DELAYED.
Cause Number
YOUR INFORMATION:
1. Attach copies of the past three (3) years of your W2's. If you did not work or file taxes, indicate so on the following line
2. Do you have any other biological or adopted children in your household? (Stepchildren/children of a significant other do not apply if not adopted or your biological child(ren). Include name(s) and date(s) of birth.
3. Do you pay a child support order for any other child(re)? If so, please give the child(rens) name(s), date of birth(s), the current support amount ordered, and the arrearage amount ordered.
4. Do you pay any maintenance payments to an ex-spouse? If so, list the amount and ex-spouse's name.
5. Do you provide Insurance for the child(ren) in this case? If so, list the cost and number of people the insurance policy covers.
6. Do you have any WORK-RELATED child day care costs? List name of provider and cost.
7. Do(es) the child(ren) stay OVERNIGHT with the other parent? If so, list the number of overnights in a one (1) year time period.
OTHER PARTY'S INFORMATION:
1. Does the other party have any other biological or adopted children? (Stepchildren/children of a significant other do not apply if not adopted or their biological children(ren). Include name(s) and date(s) of birth.
2. Does the other party pay a child support order? If so, please give the child(rens) name(s), date of birth(s), the current support amount ordered, and the arrearage amount ordered.
3. Does the other party pay any maintenance payments to an ex-spouse? If so, list the amount and exname.
4. Does the other party provide insurance for the child(ren) in this case? If so, list the cost and number of people the insurance policy covers.
5. Does the other party have any WORK-RELATED child day care costs? List name of provider and cost.
Attach copies of the past three (3) years of your W2's.
Attach Document (PDF, JPG, PNG, GIF, TIFF Only)
Enter the code here
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
