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Name:

Address:

City:

State

Zip

E-mail

Daytime Phone:

Evening Phone:

Is your court-order from a	Divorce     Paternity    Other
How many children do you have?
Do they live with you?	Yes          No
How much was the absent parent ordered to pay?
Has the absent parent ever paid anything?	Yes           No
How long has it been since the absent parent last paid you anything?
Approximately how much does the absent parent owe you?
Do you know the absent parent's social security number?	Yes           No
Do you know where the absent parent lives?	Yes           No
Do you know where the absent parent works?	Yes           No           Not working
Are you receiving TANF?	No            Yes

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