Merced — MCDCSS-123

Source: https://www.merced.courts.ca.gov/system/files/mcdss-123-mcdcs-info-sheet-rev-10022019.pdf

THIS FORM MUST BE COMPLETED AND SIGNED BEFORE Reserved for Court’s Case Number: YOUR ORDER CAN BE HEARD IN COURT OR FILED WITH THE SUPERIOR COURT CLERK’S OFFICE.

MERCED COUNTY DEPARTMENT OF CHILD SUPPORT SERVICES

NON-CUSTODIAL PARENT Full Name: Last First Middle Date of Birth: Gender:

o M o F
Month Day Year o Nonbinary
Last Number & Street City State Zip Phone:

Known ( ) Home Address: ( ) Message/Cell Description: Preferred Language: o English o Spanish

o Other ________________
Hair Eyes Height Weight
Social Security #: Driver's License or ID # Race: o White o Hispanic
o Black o Asian
o Native American o Other
Present or Last Known Employer: Name and Address of Friend or Relative:

Name of Company: Address City & State Phone

CUSTODIAL PARENT / GUARDIAN Full Name: Last First Middle Date of Birth: Gender: o M o F Month Day Year o Nonbinary Last Number & Street City State Zip Phone: Known ( ) Home Address: ( ) Message/Cell Social Security # Marriage Date: Preferred Language: o English o Spanish Dissolution Date o Other ________________ & County:

Receiving Public Assistance: o NO o YES Welfare #

CHILDREN Name of Child(ren) Date of Birth Social Security State of Birth Place: Number Conception

THIS FORM CONSTITUTES AN APPLICATION FOR SERVICES.

I UNDERSTAND THAT THE DEPARTMENT OF CHILD SUPPORT SERVICES WILL ASSIST ME IN MY EFFORTS

TO ENFORCE AND/OR MAINTAIN CHILD AND/OR MEDICAL SUPPORT FOR THE ABOVE CHILD(REN).

SIGNATURE OF: o CUSTODIAL PARENT DATE o NON-CUSTODIAL PARENT (Check One)

Revised 10/2/2019 DEPARTMENT OF CHILD SUPPORT SERVICES MCDCSS 123 COURT INFORMATION SHEET