Registration Statement {FSA-207}

REGISTRATION STATEMENT Responding IV-D Case No. Initiating IV-D Case No. Responding Docket No. Initiating Docket No. I. Case Summary (Background of this matter: Court/Administrative Actions) Date of Support Order State and County Issuing Order Date of Last Payment Amount of Arrears $ Date Obligor Obligee Address (Street, City, State, Zip) Employer/Address (Name, Street, City, Zip) Tribunal Case No. Support Amount/Frequency $ II. Mother Information Full Name and Aliases Period of Computati thru Date SSN: III. Father Information Full Name and Aliases Obligor Obligee Address (Street, City, State, Zip) Employer/Address (Name, Street, City, Zip) SSN: IV. Caretaker Information (If Not a Parent) Full Name and Aliases Address (Street, City, State, Zip) Relationship to Child(ren) SSN: V. Additional Case Information This order is registered in the following states: Description and location of any property not exempt from execution: Other: American LegalNet, Inc. www.FormsWorkflow.com VI. Verification/Certification Under penalties of perjury, all information and facts concerning the arrearage accrued under this order are true to the best of my knowledge and belief. Date Sworn t o and Signed Before Me This Date, County/State FSA -207 Registration Statement (Rev. 1-99) Party seeking Registration Records Custodian Commission Expi Notary Public, Court/Agency Official and Title OMB No. 0970-0085 American LegalNet, Inc. www.FormsWorkflow.com