MISSOURI DEPARTMENT OF SOCIAL SERVICES FAMILY SUPPORT DIVISION REFERRAL/INFORMATION FOR CHILD SUPPORT SERVICES
THIS SECTION TO BE COMPLETED BY INCOME MAINTENANCE STAFF
APPLICANT’S DEPARTMENTAL CLIENT NUMBER (DCN)	TEMPORARY ASSISTANCE	MEDICAID–ONLY
THIS SECTION TO BE COMPLETED BY THE APPLICANT
COMPLETE EVERY ITEM ON THIS FORM EVEN IF YOU HAVE GIVEN THE INFORMATION BEFORE. THIS FORM REQUESTS INFORMATION NEEDED TO TAKE ACTION ON YOUR CHILD SUPPORT CASE.
THE APPLICANT IS (i.e., relationship to the child)► MOTHER FATHER GRANDPARENT OTHER _______________________
CUSTODIAL PARENT/CUSTODIAN INFORMATION
NAME (LAST)	(FIRST)	(MIDDLE)
ADDRESS (NUMBER AND STREET)	(CITY)	(STATE)	(ZIP CODE)
HOME PHONE NUMBER (INCLUDE AREA CODE)	CELL PHONE NUMBER (INCLUDE AREA CODE)	WORK PHONE NUMBER(INCLUDE AREA CODE)
SOCIAL SECURITY NUMBER	DATE OF BIRTH	RACE	SEX
NONCUSTODIAL PARENT or ALLEGED FATHER INFORMATION
NAME (LAST)	(FIRST)	(MIDDLE)	ALIAS
ADDRESS (CURRENT OR LAST KNOWN)	(CITY)	(STATE)	(ZIP CODE)
DATE ADDRESS LAST KNOWN	PHONE NUMBER (INCLUDE AREA CODE)	CELL PHONE NUMBER (INCLUDE AREA CODE)	SOCIAL SECURITY NUMBER
DATE OF BIRTH	BIRTHPLACE (CITY AND STATE)	RACE	SEX
CHILDREN OF THE CUSTODIAL PARENT AND NONCUSTODIAL PARENT/ALLEGED FATHER
CHILD’S DCN OR SSN	NAME (LAST, FIRST, MIDDLE)	DATE OF BIRTH	COUNTY/STATE OF BIRTH	RACE	SEX
IF THE CHILD(REN) WERE BORN OUT OF STATE, ATTACH A COPY OF THE BIRTH CERTIFICATE, IF AVAILABLE.
MARITAL STATUS AND COURT INFORMATION
ARE THE PARENTS OF THE CHILD(REN) MARRIED? NEVER MARRIED? FILED FOR DIVORCE? DIVORCED?
IF THE PARENTS ARE/WERE MARRIED, PROVIDE DATE AND LOCATION	►	DATE	LOCATION (CITY, COUNTY AND STATE)
IF THE PARENTS ARE DIVORCED OR HAVE FILED FOR DIVORCE, PROVIDE DATE AND LOCATION	►	DATE	LOCATION (CITY, COUNTY AND STATE)
DID THE CUSTODIAL PARENT OF THE CHILD(REN) LIVE OUTSIDE MISSOURI AFTER THE CHILD(REN)’S BIRTH?
YES	NO	UNKNOWN
IF YES	►	WHERE (CITY, COUNTY AND STATE)	WHEN
WAS THE MOTHER MARRIED TO A MAN OTHER THAN THE NONCUSTODIAL PARENT/ALLEGED FATHER WHEN SHE
BECAME PREGNANT OR WHEN THE CHILD(REN) WAS/WERE BORN?	YES	NO	UNKNOWN
IF YES, GIVE NAME	►	NAME	DATE OF MARRIAGE
HAVE CHILD SUPPORT PAYMENTS BEEN ORDERED BY A COURT?
YES (ATTACH A COPY OF THE ORIGINAL COURT ORDER AND ANY MODIFICATIONS)	NO	UNKNOWN
IF YES, COMPLETE COURT INFORMATION	►	COUNTY AND STATE OF COURT ORDER	DATE OF ORDER
ORDER NUMBER	AMOUNT PER CHILD $	FREQUENCY (WEEKLY, MONTHLY, ETC.)
COMPLETE THE FOLLOWING IF THE PARENTS WERE NOT MARRIED WHEN THE CHILD(REN) WERE BORN
HAS PATERNITY BEEN LEGALLY ESTABLISHED BY A COURT?	YES (ATTACH A COPY OF THE COURT ORDER)	NO
IF YES, COMPLETE COURT INFORMATION	►	COUNTY AND STATE OF COURT ORDER	DATE OF ORDER	ORDER NUMBER
HAS THE ALLEGED FATHER COMPLETED A DOCUMENT ADMITTING HE IS THE FATHER OF THE CHILD(REN)?
NO	YES (ATTACH A COPY OF THE DOCUMENT)	IF YES, IN WHICH STATE?
HAS A PATERNITY TEST BEEN COMPLETED TO DETERMINE THE BIOLOGICAL FATHER OF THE CHILD(REN)?
NO	YES (ATTACH A COPY OF THE RESULTS)	IF YES, IN WHICH STATE?
IS IT POSSIBLE THAT ANOTHER MAN, OTHER THAN THIS ALLEGED FATHER, MIGHT BE THE FATHER OF THE CHILD(REN)
LISTED? (ATTACH ADDITIONAL SHEET IF NECESSARY)	YES	NO
IF YES	►	NAME	ADDRESS	PHONE NUMBER (INCLUDE AREA CODE)
NAME	ADDRESS	PHONE NUMBER (INCLUDE AREA CODE)
OCCUPATIONAL AND SOCIAL INFORMATION
IS THE NONCUSTODIAL PARENT/ALLEGED FATHER NOW EMPLOYED?	YES	NO	UNKNOWN
IF YES	►	NAME OF EMPLOYER	PHONE NUMBER (INCLUDE AREA CODE)
ADDRESS	WORK HOURS FROM TO
WHAT ARE THE NAMES AND ADDRESSES OF THE NONCUSTODIAL PARENT’S/ALLEGED FATHER’S PARENTS?
FATHER’S NAME	FATHER’S ADDRESS
MOTHER’S NAME	(MAIDEN NAME)	MOTHER’S ADDRESS
About our request for Social Security number (SSN) information: We need your SSN and that of your child(ren); the SSNs will be used to locate individuals for purposes of establishing paternity and establishing, modifying, and enforcing support obligations. Disclosure of these SSNs is mandatory per section 466(a)(13) of the Social Security Act. We also ask that you provide the noncustodial parent’s or alleged father’s SSN if you know it. We need this information in order to identify the other parent in our records, to establish a support order, or to enforce a support order. Failure to provide this information may cause delays in delivering appropriate services to you.
I certify that all information I gave on this form is true and complete to the best of my knowledge.
APPLICANT SIGNATURE	DATE
THIS SECTION TO BE COMPLETED BY INCOME MAINTENANCE STAFF
WORKER’S NAME (PLEASE PRINT)	IM OFFICE	DATE
NOTATIONS OF INCOME MAINTENANCE WORKER
Return the completed form to: Family Support Division, PO Box 6790, Jefferson City, MO 65102–6790.