Fillable COURT CODE: CSPI NEVADA STATE DIVISION OF WELFARE

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COURT CODE: CSPI NEVADA STATE DIVISION OF WELFARE

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NEVADA STATE DIVISION OF WELFARE AND SUPPORTIVE SERVICES
CHILD SUPPORT ENFORCEMENT
IN THE FAMILY DIVISION
OF THE ______________ JUDICIAL DISTRICT COURT OF THE STATE OF NEVADA
IN AND FOR THE COUNTY OF _______________
CONFIDENTIAL FAMILY COURT INFORMATION SHEET
Case No.
Plaintiff/Petitioner
vs.
Dept. No.
Defendant/Respondent
Mother/Wife Information
Custodial Parent Non-Custodial Parent
Father/Husband Information
Custodial Parent Non-Custodial Parent
Name: Name:
Social Security Number: Social Security Number:
Date of Birth: Date of Birth:
Residential Address: Residential Address:
City, State, Zip:
City, State, Zip:
Mailing Address: Mailing Address:
Telephone No.: Telephone No.:
Driver’s License No.: Driver’s License No.:
Ethnicity: White (Non Hispanic) Hispanic
African-American Asian or Pacific Islander
Native American/Alaskan Native Other
Ethnicity:
White (Non Hispanic) Hispanic
African-American Asian or Pacific Islander
Native American/Alaskan Native Other
Are you employed? YES NO Are you employed? YES NO
Name of Employer: Name of Employer:
Business Address: Business Address:
City, State, Zip: City, State, Zip:
Telephone No.: Telephone No.:
CHILDREN OF THE PARTIES
Gender
Name
: SSN: DOB:
M F
Name: SSN: DOB:
M F
Name: SSN: DOB: M F
Name: SSN: DOB: M F
Name: SSN: DOB: M F
If there are more than five (5) children, list their inform
ation on a separate sheet of paper and attach.
Does this case involve Family Violence: YES NO
Signature Date Signature Date
(Page 1 of 2) 4094 - EC (4/10)
COURT CODE: CSPI
8th
CLARK
/s/
/s/
The information captured on this form will be forwarded to the Federal Case Registry as
required by federal law. If you do not want your identifying information shared with other
states because of domestic violence, please check YES to the question on domestic
violence.
Nevada’s Division of Welfare and Supportive Services (DWSS), Child Support
Enforcement Program (CSEP) is required by Chapter 42 of the United States Codes,
federal regulations and state laws to obtain the Social Security Numbers (SSNs) of
participants in cases involving child support orders. The CSEP will use these SSNs only
for the purposes outlined in the federal law, federal regulations, state laws and state
regulations that govern the CSEP. Social Security Numbers will be maintained in a
confidential manner.
Within ten (10) days after a Nevada court issues a child support order, each party listed in
the order must file the following information with the court that issued the order and the
Division of Welfare and Supportive Services:
1. Social Security Number;
2. Residential and mailing address;
3. Telephone number;
4. Driver’s License number, and
5. Name, address and telephone number of employer.
Each party shall update the information filed with the court and the Division of Welfare
and Supportive Services (DWSS) within ten (10) days after the information becomes
inaccurate. Information directed to DWSS should be mailed to:
Nevada State Division of Welfare and Supportive Services
Child Support Enforcement Program
1470 College Parkway
Carson City, Nevada 89706-7924
This requirement can be found in Nevada Revised Statutes 125B.055 and 125.230.
(Page 2 of 2) 4094 - EC (4/10)
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Completed 9 December 2020

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