Today's Date:

Name:

Street Address:

City:

Zip Code:

Marital Status:

Phone:

Email:

Date of Birth:

Gender:
Male Female
Race:

Social Security Number:

Are Children in the state of Florida?
Yes No
Child Support Case/Docket Number:

Monthly Child Support Amount:

Referred By:

DOR   Court   Website   Other  

Custodial Parent Name(s) & date of birth or age:
 
 

Children Name(s) & date of birth or age:
 
 
 
 

Select all that apply for the non-custodial parent (NCP)

Having difficulty paying child support

Unemployed

Under-employed / needing another job

Driver's license suspended for child support

Smoking status: Never Smoked Current some day smoker Current every day smoker Former Smoker / Tobacco User Trying to quit smoking / Tobacco

Steady Transportation: Yes No

Military Veteran: Yes No

Have a resume: Yes No

Have a: High School Diploma G.E.D. No diploma or G.E.D.

Highest Grade Completed:

Work Experience:

Enrolled in school/training program: Yes No Type:

Legal background: No Yes Felony Misdemeanor