Merced County Department Of Child Services Court Information Sheet {MCDSS-123}

THIS FORM MUST BE COMPLETED AND SIGNED BEFORE YOUR ORDER CAN BEHEARD IN COURT OR FILED WITH THE SUPERIOR COURT CLERK'S OFFICE.MERCED COUNTY DEPARTMENT OF CHILD SUPPORT SERVICESNON-CUSTODIAL PARENT Full Name:LastFirstMiddleDate of Birth:Sex:MonthDayYear LastNumber & StreetCityStateZipPhone:KnownHomeAddress:Message/Cell Description:Race:WhiteHispanicBlackAsianHairEyesHeightWeightNative AmericanOther Present or Last Known Employer:Name of CompanyAddressCity & StatePhone Social Security Number:Drivers License #:Name & Address of Friend or Relative:CUSTODIAL PARENT Full Name:LastFirstMiddleDate of Birth:Sex:MonthDayYear LastNumber & StreetCityStateZipPhone:KnownHomeAddress:Message/Cell Social Security Number:Marriage Date:Dissolution Date & CountyWelfare #: (If Aided)CHILDREN Name of Child(ren)Date of BirthSocial Security #State of ConceptionBirth Place THIS FORM CONSTITUTES AN APPLICATION FOR SERVICES.IUNDERSTAND THAT THE DEPARTMENT OF CHILD SUPPORT SERVICES WILL ASSIST ME IN MY EFFORTS TO ENFORCE AND/ORMAINTAIN CHILD AND/OR MEDICAL SUPPORT FOR THE ABOVE CHILD(REN). SIGNATURE OF:CUSTODIAL PARENTDATENON-CUSTODIAL PARENT(Check One) DEPARTMENT OF CHILD SUPPORT SERVICESCOURT INFORMATION SHEET 001001001001001001001001 American LegalNet, Inc. www.FormsWorkFlow.com