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