Last updated: 8/7/2006
Non IV-D Demographic Information And Update Worksheet {045}
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Description
DATE:___/___/___ Please Check On oef the Following: Original Order Please Check On Only e: State Case Registry Modified Order Centralized Collections Update Order Both of the Above Complete and fax one copy to: (888) 701-3073 NON IV-D DEMOGRAPHIC INFORMATION & UPDATE WORKSHEET (Please Print Legibly) YOU ARE HEREBY PLACED ON NOTICE THAT : when the COURT enters an ORDER in which the paternity of a child is determinORed support is ordered, enforced or modifieead,c h party is immediatel rey quired to file with the COURT AND if the case is a Title IV-D child support case, with the local Title IV-D child support office, the following information for the individual who is AS a partyWELL AS the following information foear ch Child. You must also update this information within ten (10) days of any change. T.C.A. 36-5-101(a)(4)(B). To comply with this law for filing this required information with tOUhisR CT, you may use this form. The local Title IV-D child support office may require a different form for any filing required with their office. Failure to c woithmp tlhyis LAW may result in the Courts Order not being signed or effec tive. COURT CODE 4706505 DOCKET N0. ____________ ORIGINAL ORDER DATE: _____/_____/_____ FAMILY VIOLENCE INDICATOR YES NO PLAINTIFF INFORMATION _________________________________________________________________________________________ _____/_____/_____ [Full name and any change in name Social Security Number] ____________________________________________________________________________________________________________ [Residential and mailing addresses] _____________________________ ________ $_____________________________________ (____)______________________ [Driver license number State Gross annual income Home telephone numbe] rs______________________________________________________________________________ (____)______________________ [Employer name Employers address Employers telephone num] ber____________________________________________________________________________________________________________ [Availability and cost of health insurance for child(ren)] DEFENDANT INFORMATION _________________________________________________________________________________________ _____/_____/_____ [Full name and any change in name Social Security Number] ____________________________________________________________________________________________________________ [Residential and mailing addresses] _____________________________ ________ $_____________________________________ (____)______________________ [Driver license number State Gross annual income Home telephone numbe] rs______________________________________________________________________________ (____)______________________ [Employer name Employers address Employers telephone num] ber____________________________________________________________________________________________________________ [Availability and cost of health insurance for child(ren)] DEPENDENT INFORMATION 1____________________________________________________________________________Sex: F M _____/_____/_____ [Full name and any change in name Date of Birth] ________________________________________________________________________________________ _____/_____/_____ [Residential and mailing addresses Social Security N0] .2____________________________________________________________________________Sex: F M _____/_____/_____ [Full name and any change in name Date of Birth] ________________________________________________________________________________________ _____/_____/_____ [Residential and mailing addresses Social Security N0] .3____________________________________________________________________________Sex: F M _____/_____/_____ [Full name and any change in name Date of Birth] ________________________________________________________________________________________ _____/_____/_____ [Residential and mailing addresses Social Security N0] .4____________________________________________________________________________Sex: F M _____/_____/_____ [Full name and any change in name Date of Birth] ________________________________________________________________________________________ _____/_____/_____ [Residential and mailing addresses Social Security N0] . [Form 045, Rev. 1999.10.26]
