Child Support Intake

Client Information

What office would you like to work with?*
Associate working with you on your case:*
How did you hear about us:*
Name:*
Mailing Address:*
Phone #1:*
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Phone#2:
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E-mail:*
Social Security Number:
Driver License & Issuing State:
Date of Birth:*
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Government Assitance

Do you receive government assistance?:*
If so, what do you receive?: Click all that apply
Upload the award letter or proof of assistance:

Opposing Party Information

Opposing Party Name:*
Address:*
Social Security Number:
Date of Birth:
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Phone#1:
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Phone#2:
-
E-mail:
Driver License & Issuing State:

Opposing Party Employment Information

Employer Name:
Employer Address:
If unemployed, give estimated date of when they last worked:
Employer Phone:
-
Occupation or Job Title:
Date of Hire:
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Gross Monthly Earnings:
What were their gross monthly earnings at that time:

Process Server Information

Would you like for us to serve the documents?: (Note: Process Server will attempt up to 3 times at the same location if you need process server to attempt more times or a different location additional fees may apply.)*
Where would you like us to serve the documents?:
If you would like for us to serve the documents what address would you like them served at?:
What is the best time to serve the documents to Opposing Party?
What is the description of the vehicle they drive?:
What is your Opposing Party Ethnic background:
Hair Color:
Eye Color:
Height:
Weight:

Minor Children of This Relationship

***If there are no children skip this section.***


1. Child's Full Name:
Sex:
Date of Birth: 1(4)(5)
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Social Security Number:
Place of Birth:


2. Child's Full Name:
Sex:
Date of Birth: 1(4)(6)
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Social Security Number:
Place of Birth:


3. Child's Full Name:
Sex:
Date of Birth: 1(4)(4)
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Social Security Number:
Place of Birth


4. Child's Full Name:
Sex:
Date of Birth: 1(4)(3)
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Social Security Number:
Place of Birth:


5. Child's Full Name:
Sex:
Date of Birth: 1(4)(2)
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Social Security Number:
Place of Birth:


6. Child's Full Name:
Sex:
Date of Birth: 1(4)(1)
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Social Security Number:
Place of Birth:

Questions Regarding the Child(ren)

What type of legal custody would you like?*
What type of physical custody would you like?*
What is the proposed visitation for the child(ren) (Example: Every 1st and 3rd weekend of the month commencing Friday at 6pm to Sunday at 6pm or you don't have a set schedule you can just say that you would like to award spouse liberal visitation either way it must be addressed in the box below)**If this section does not apply to you just type N/A**:*
Will child support be reserved or is there an agreement? If there is an agreement please continue to the following question:*
Please fill out the following:

Minor Children Living In Your Home From Another Relationship?

***If there are no children skip this section.***

1. Child's Full Name:
Sex:
Date of Birth: 1(4)
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Social Security Number:
Place of Birth:


2. Child's Full Name:
Sex :
Date of Birth: 1(3)
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Social Security Number:
Place of Birth:


3. Child's Full Name:
Sex :
Date of Birth: 1(2)
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Social Security Number:
Place of Birth:


4. Child's Full Name:
Sex :
Date of Birth: 1(1)
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Social Security Number:
Place of Birth:

Income and Expense Declaration

***The court requires that you answer truthfully and correctly the following information.

Are you employed?:*

Employment

(Give information on your current job or if you are unemployed, your most recent job)

Employer:*
Employer Address:*
Employer's Phone Number:*
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Occuption:*
Date job started:
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If unemployed, date job ended:
How many hours per week do you work?
How much do you get paid per month (before taxes)?*

Age and Education


How old are you?*
What is the highest level of education completed?*
What Degree or Certification did you receive in:

Tax Information

When was the last year you filed taxes?*
What was your filing status? (Single, Head of Household, Married filing separately, Married, filing jointly):*
In what state did you last file?*
I claim the following number of exemptions (including myself) on my taxes:

Other Party's Income

What is Opposing Party estimated gross income (before taxes):*

Income

***List either last month's income, or average monthly income. Fill out all that apply.***

Either Previous month or Average monthly.

Salary or wages (gross, before taxes)
Overtime (gross, before taxes)
Public Assistance (Example: TANF, SSI, Cash Aid, GA/GR):
Spousal Support:
Partner Support:
Pension/Retirement fund payments:
Social Security Retirement:
Social Security Disability:
State Disability:
Private Insurance Disability:
Unemployment Compensation:
Workers' Compensation:
Other (Military BAQ, Royalty payments, etc) (specify):

Investment Income

Either Previous month or Average monthly.

Dividends/interest:
Rental Property Income:
Trust income:
Other (specify):
Upload schedule showing gross receipts less cash expenses for each piece of property:

Income from self-employment, after business expenses for all business.

Self-employment Income:
I am the (of the business):
Other (specify):
Number of years in this business:
Name of business:
Type of business (specify):
Upload a profit and loss statement for the last two years or a schedule C from your last federal tax return. If you have more than on business provide for each business.:
Additional Income I received one time money (lottery winnings, inheritance, etc.) in the last 12 months (specify source and amount):
Change in income. My financial situation has changed significantly over the last 12 months because (specify):

Deductions

(Last month)

Required unions dues:
Required retirement payments (not Social Security, FICA, 401(k), or IRA)
Medical, hospital, dental, and other health insurance premiums (total monthly amount)
Child support that I pay for children from other relationships
Spousal support that I pay by court order from a different marriage
Partner support that I pay by court order from a different domestic partnership
Necessary job-related expenses not reimbursed by my employer. Specify amount and explain to support amount:

Assets

List Total

Cash and checking accounts, savings, credit union, money market, and other deposit accounts:
Stock, bonds, and other assets I could easily sell
All other property, real and personal (estimate fair market value minus the debts you owe)

The following people live with me:


.

Average monthly expenses:


The following are:
Rent
Mortgage
Average Pricipal
Average interest
Real property taxes
Homeowner's or renter's insurance (if not included above)
Home Maintenance and repair
Health-care costs not paid by insurance
Child care
Groceries and household supplies
Eating out
Utilities (gas, electric, water, trash)
Telephone, cell phone, Internet
Laundry and cleaning
Clothes
Education
Entertainment, gifts, and vacation
Auto Expenses and transportation (insurance, gas, repairs, bus etc.)
Insurance (life, accident, etc,; do not include auto, home, or health insurance)
Savings and investments
Charitable contributions
Other (specify)
Installment payments and debts not listed above
Name of Insurance Company
Does your job provide health insurance to your child(ren)
Address of insurance company:
The monthly cost for the child(ren's) health insurance is or would be (Do not include the amount your employer pays)
Child care so I can work or get job training
Children's health care not covered by insurance
Travel expenses for visitation
Notes (additional information you would like to add, such as information regarding opposing party information that would help you receive the custody you seek):
Children education or other special needs (specify amount and what it is)
Please provide the residence address for each child of this relationship for the last five (5) years:
What is your goal:*
If you are attempting to modify previous orders or have a Child support case please submit all documents pertaining to case.

Please read the following carefully sign and date by printing your name you are signing this document electronically.

´╗┐I declare under the penalty of perjury under the laws of the state of California that the foregoing is true and correct. I also Understand that Legal Service Centers will prepare all legal documents at my direction. I understand there may be additional fees if the matter becomes contested, as well as additional filing fees, process service fees, or court runner fees. If any amendments , or additional documents are prepared there will be additional fees that will apply. I understand Legal Service Centers DOES NOT ISSUE REFUNDS.


By typing my name bellow I understand that that I am signing this document electronically.*
Today's Date:*
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