1.     Information regarding petitioner and respondent. (Look at the paperwork you are giving to the court to see who is listed at the top as petitioner and respondent. Use a separate sheet if necessary.)

Petitioner                    Respondent
Name: ___________________________    Name: ____________________________
(Last name, first, middle)            (Last name, first, middle)
Other names (e.g. maiden name):        Other names (e.g. maiden name):
_________________________________    ___________________________________
Address: __________________________    Address: __________________________
City: _____________________________    City: _____________________________
State: ____________________________    State: ____________________________
Zip code: _________________________    Zip code: _________________________
Date of birth: _____________________    Date of birth: ____________________
Social Security number 2: ____________    Social Security number 2: _____________

2.     Parties' minor children. (Provide the date of birth and social security number for each minor child, if any. Use a separate sheet if necessary.)

Name: ____________________________    Name: _______________________________
(Last name, first, middle)            (Last name, first, middle)
Date of birth: _______________________    Date of birth: __________________________
Social Security number: _______________    Social Security number: _________________

Name: ____________________________    Name: _______________________________
(Last name, first, middle)            (Last name, first, middle)
Date of birth: _______________________    Date of birth: __________________________
Social Security number: _______________    Social Security number: _________________

Has any court made an order for child support? ___Yes ___No

Has any court changed the amount of child support you requested? ___Yes ___No

If your answer is "Yes" to either question, what state and what court are they located in? ______________ State __________ Court.

3.    Request to limit access to information.
    (Optional - complete only if applicable)
    [ ]    I have reason to fear domestic violence or child abuse. For this reason, please limit access to information about me in the Child Support & Paternity Case Registry to the extent possible. I realize that this request may make it more difficult to assist me in collecting child support. I also understand that the other party and the public might still view information about my case under some circumstances.
    Under penalty of perjury, I affirm that this request is legitimately made and not designed to harass or intimidate the other party or mislead the court.

NOTE TO COURT CLERK:
DO NOT PLACE THIS INFORMATION SHEET IN THE COURT FILE. 3

If you need more space to write, you can attach a separate sheet with the information.

To Petitioner:

If you and your spouse or the other person who owes child support have agreed on everything before this case was filed, then you must give the Information Sheet to the court clerk with your petition.

If you do not agree it means the case is contested. If the case is contested, you MUST do two things:

1.    give the information sheet to the court clerk; and

2.    have a sheriff or process server give a blank copy of the Information Sheet to your spouse or other person who owes child support.

To Respondent:

You must submit the information sheet when you file your first paper with the court. You must write the name of the judge and the case number on the Information Sheet. You can find that information on the papers the petitioner gave you.

After you fill out this form, you will need to submit the other paper work required by law.
If you choose to represent yourself in a claim, you may still wish to talk with an attorney to discuss your rights. The people who work in the court cannot give you legal advice.

Purpose:

You must give the information requested on the sheet for the State Case Registry. This information is required by federal and state law. The information is needed to identify and keep up with your case. If your child(ren) do not receive the child support ordered, this information will help the court get the money for your child(ren).

If you have more than one social security number, include all social security numbers. Social security numbers will be given to state and federal agencies which are required by law to collect the information. Social security numbers will not be given to the public.

Your addresses are used by the court to obtain feedback from both of you.

    1.    The information contained in the "official use only" section of the Domestic Relations Information Sheet, including the case number and assigned judge will be filled in by the court clerk.

    2.    If the party has more than one social security number, please include it.

    3.     Unless there are more than four children, the information sheet is to be submitted on a single page. The clerk will key-enter the information on the information sheet. The information sheet will not be filed in the court file. The Domestic Relations Information Sheet Instructions are not submitted to the court clerk.

    4.    The Child Support & Paternity Case Registry is a required, nationwide database of child support and paternity orders. Access to registry information is strictly limited to court and child support administrative personnel. Requesting that your registry information be "nondisclosed" does not prevent authorized parties from reviewing the information. Rather, it alerts courts and child support administrative personnel to act with caution when viewing your information. However, be aware that requesting "nondisclosure" of registry information does not limit access to your official district court case file which is a public record. If you are concerned about such access, ask your lawyer, or the court clerk if you do not have a lawyer, about ways in which the court may restrict access to your court file.

[Provisionally approved, effective November 1, 1999 to November 1, 2000; approved, as amended, effective November 1, 2000.]