SUPPORT QUESTIONNAIRE - California Department of …

1 CW (Q) (10/16) SUPPORT QUESTIONNAIRE REQUIRED FORM SUBSTITUTE PERMITTED1st Copy Local Child SUPPORT Agency2nd Copy County Welfare Department3rd Copy ApplicantSTATE OF California - HEALTH AND HUMAN SERVICES AGENCYCALIFORNIA Department OF SOCIAL SERVICESSUPPORT QUESTIONNAIREINSTRUCTIONS:You must answer ALL ONE FORM FOR EACHNONCUSTODIAL PARENT OR EACH UNMARRIEDFATHER IN THE ink. Print answer. Check Yes, No, or a separate piece of paper if you need more 1 - COMPLETE THE FOLLOWING ABOUT YOURSELFFOR COUNTY USE ONLYCWD CASE NAMECWD CASE NUMBERCWD WORKER NUMBER( )TELEPHONE NUMBER( )LCSA CASE NAMELCSA CASE NUMBERLCSA WORKER (FIRST, MIDDLE, LAST)ZIPHOME ADDRESS (STREET NUMBER AND NAME, APARTMENT NUMBER, IF ANY)CITYTELEPHONE NUMBER( )YOUR RELATIONSHIP TO CHILDRENYOUR RELATIONSHIP TO NONCUSTODIAL PARENT/UNMARRIED FATHER IN THE HOME Spouse Ex-Spouse Friend OtherSOCIAL SECURITY NUMBER (SSN)

2 MAIDEN NAMEBIRTHDATESTATERACEBIRTH PLACESECTION 2 - COMPLETE THE FOLLOWING ABOUT THE NONCUSTODIAL PARENT ORUNMARRIED FATHER IN THE HOMELAST KNOWN ADDRESS (STREET NUMBER AND NAME, APARTMENT NUMBER, IF ANY)SOCIAL SECURITY NUMBER (SSN)WHEN WAS THIS ADDRESS CURRENT?WHEN DID YOU LAST HEAR FROM OR GET MAIL FROMTHIS PARENT?CITYDoes this parent livewith you?SCARS, BIRTHMARKS, TATTOOS, NICKNAMES, PLACERACE Yes No MALE FEMALEHEIGHTSTATEZIPWEIGHTEYE COLORHAIR (FIRST, MIDDLE, LAST)TELEPHONE NUMBER( ) Yes, Union Name No UnknownUNION MEMBER?LAST KNOWN EMPLOYERSTREET ADDRESSWHEN DID THIS PARENT LAST WORK THERE?

3 UNION ADDRESS:TYPE OF WORKCITYSTATEZIP Earnings Social Security None OtherB. WHAT KIND OF INCOME DOESNONCUSTODIAL PARENT HAVE?Unemployment orDisability InsuranceBenefitsTELEPHONE NUMBER( ) MARRIED DATE _____ DIVORCED DATE _____ WHERE_____WHERE _____ WHO IS COVERED?NAME OF INSURANCEPOLICY NUMBERDATE OF COVERAGE Yes No THIS PARENT HAVE HEALTHINSURANCE FOR THE CHILDREN? AREOR HAVE BEEN SEPARATED NEVER MARRIED LIVING TOGETHER1st Copy Local Child SUPPORT Agency2nd Copy County Welfare Department3rd Copy Applicant PATERNITY DECLARATIONCW (Q) (10/16) SUPPORT QUESTIONNAIRE REQUIRED FORM SUBSTITUTE PERMITTEDSTATE OF California - HEALTH AND HUMAN SERVICES AGENCYCALIFORNIA Department OF SOCIAL SERVICES Yes No Pending Pays Household Bills To You To County Payroll Deduction OtherHow does the parent pay?

4 WHEN DID PARENT LAST PAY?AMOUNT ORDERED$HOW OFTEN?DATE OF COURT ORDERCOURT ORDER NUMBERLOCATION OF COURT (COUNTY & STATE)HOW MUCH?$E. IS THERE A COURT ORDER FOR SUPPORT ?ADDRESS ( NUMBER AND STREET)RELATIONSHIP TO NONCUSTODIAL OF A FRIEND OR RELATIVE OF NONCUSTODIAL PARENTTELEPHONE NUMBER( )vehicles? Yes No UnknownMAKEMODELYEARLICENSE this parent own any motor Yes No this parent own a house, land, buildings, or bank accounts? this parent currently on probation or parole? Yes No UnknownWHAT COUNTY OR STATE? this parent ever been in jail or prison? Yes No UnknownIF YES, WHEN/WHERE? this parent ever been in the military?

5 You able to identify or help locate the noncustodial parent? Yes NoIF YES, WHEN/WHAT BRANCH? Yes No UnknownSECTION 3 - CHILDREN (IN YOUR HOME) OF THIS PARENT OR UNMARRIED FATHER SSNBIRTHPLACE, CITY, STATEBIRTHDATE YES NO UNKDATE SIGNEDCOUNTYNAME OF CHILD M FSSNBIRTHPLACE, CITY, STATEBIRTHDATE YES NO UNKDATE SIGNEDCOUNTYNAME OF CHILD M FSSNBIRTHPLACE, CITY, STATEBIRTHDATE YES NO UNKDATE SIGNEDCOUNTYNAME OF CHILD M FSSNBIRTHPLACE, CITY, STATEBIRTHDATE YES NO UNKDATE SIGNEDCOUNTYNAME OF CHILD M FSECTION 4 - SUPPORT ENFORCEMENT SERVICES (MEDI-CAL ONLY) I don t want other child SUPPORT enforcement DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE UNITED STATES OF AMERICA AND THE STATE OFCALIFORNIA THAT THE INFORMATION IN THIS QUESTIONNAIRE IS TRUE, CORRECT AND