STATE OF WASHINGTON
DEPARTMENT OF SOCIAL AND HEALTH SERVICES
DIVISION OF CHILD SUPPORT (DCS)
CHILD SUPPORT REFERRAL
The Division of Child Support will use your personal information and social security number for child support enforcement
purposes as defined in Title IV-D of the Social Security Act.
A. INFORMATION ABOUT THE CHILDREN'S PARENTS
MOTHER OF CHILDREN
FATHER OF CHILDREN
Name (First/Middle/Last):
Name (First/Middle/Last):
Other Names Used:
Other Names Used:
P.O. Box or Street Address:
P.O. Box or Street Address:
City:
State:
ZIP Code:
City:
State:
ZIP Code:
Message Telephone Number:
Message Telephone Number:
Home Telephone Number:
Home Telephone Number:
(
)
(
)
(
)
(
)
Social Security Number:
Date of Birth (Month/Day/Year): Social Security Number:
Date of Birth (Month/Day/Year):
Place of Birth (City/County/State/Country):
Place of Birth (City/County/State/Country):
Hair Color:
Eye Color:
Hair Color:
Eye Color:
Race:
Height:
Weight:
Race:
Height:
Weight:
Native Language (If correspondence needed in other than English):
Native Language (If correspondence needed in other than English):
If enrolled in an Indian Tribe, name of the Tribe:
If enrolled in an Indian Tribe, name of the Tribe:
Lives on an Indian Reservation?
No
Yes
Lives on an Indian Reservation?
No
Yes
Last-Known Employer's Name:
Last-Known Employer's Name:
Employer's P.O. Box or Street Address:
Employer's P.O. Box or Street Address:
Employer's City:
State:
ZIP Code:
Employer's City:
State:
ZIP Code:
Employer's Telephone Number:
Employer's Telephone Number:
(
)
(
)
Mother's Mother's Maiden Name:
Father's Mother's Maiden Name
Mother's Father's Name:
Father's Father's Name:
B. THE CHILDREN'S RESIDENCE
The children listed on page 2 live with:
Mother
Father
Other (specify):
C.
IF THE CHILDREN DO NOT LIVE WITH THE MOTHER OR FATHER, COMPLETE THIS SECTION
Your Name:
Your P.O. Box or Street Address:
Your Social Security Number:
Your City:
Your State:
Your ZIP Code:
Your Telephone Number:
Your Relationship to the Children:
(
)
CHILD SUPPORT REFERRAL