Child Residency and Support Information Worksheet

    Client Name

    Email Address

    Children subject to this proceeding:

    Childs Name Date of Birth Social Security No. Sex Place of Birth

    Please list any additional children on another sheet of paper and attach to this form.

    Child Residency

    The Court requires information as to the children's place of residence for the past five years. Please provide month/year dates for residency for the children.

    to present, the children lived at (address)

    Names of who lived in the home

    Relationship to the child




    Names of who lived in the home

    Relationship to the child




    Names of who lived in the home

    Relationship to the child

    If the residency information for each child is not the same, please indicate that, and provide the information for each child. For the purposes of this form, we will assume that the children have always shared residences.

    Other Claims of Custody

    Does anyone else have a claim of custody of the children subject to this proceeding other than you and the other party?

    Are there any other pending custody proceedings in California or elsewhere concerning these children?

    If you answered yes to either of the above, you will need additional paperwork from our office.

    Child Support and Dependency Information

    Is health insurance for your child/ren available through your employer?

    If yes, please indicate how much is actually paid monthly by you for the insurance:

    $

    Insurance Information:

    Name of Carrier:

    Address of carrier:

    Policy or group policy number:

    Actual timeshare of physical time spent with child/ren

    Percentage with mother:

    Percentage with father:

    Is childcare provided for the child/ren?

    Monthly amount currently being paid by mother

    $

    Monthly amount currently being paid by father

    $

    Uninsured health care costs for child/ren: Please for each cost, state the purpose for the cost, and the estimated yearly, monthly or lump sum payment made by each parent:

    Educational or other special needs of the children. Please for each cost, state the purpose for the cost, and the estimated yearly, monthly or lump sum payment made by each parent:

    Travel expenses for visitation (if applicable):

    Monthly amount currently paid by mother

    $

    Monthly amount currently paid by father

    $

    Hardship Deductions

    Some children have special needs, or if you have children from a previous relationship that you are not receiving support for, you will need to fill out the following information.

    Expense type Amount paid monthly Approximate number of months remaining for payments
    Extraordinary health care expenses (attach supporting documents)
    Uninsured catastrophic losses (attach supporting documents)
    Minimum basic living expenses of dependent minor children, from previous relationships who live with you (attach names and ages)

    Personal Information

    The Court requires a filing on any case where child support is being paid or is reserved with personal information pertaining to each parent. Please complete all of your information, and as much information as you have about the other parent.

    Father's Information:

    Name

    Social Security No

    Street Address

    City

    State

    Zip

    Mother's Information:

    Name:

    Social Security No

    Street Address

    City

    State

    Zip

    Mailing Address

    Drivers license No

    State

    Telephone Number

    Occupation

    Employers Name

    Mailing Address

    Drivers license No

    State

    Telephone Number

    Occupation

    Employers Name