Page 7

18867TPe

Parents Not Living in the Home (TANF and Medical Assistance Only) We can help you get child support for the children for whom you are applying. Please tell us about any absent parents (any parents not living with their child). However, you could have a good reason for not telling us about an absent parent. If you are afraid that an absent parent might hurt you or someone in your family, then you have a good reason. If you have a good reason, then you do not have to give any information now. Do you have a good reason for not telling us about an absent parent? �� Yes �� No If NO, then you need to fill in the information below. Child with Absent Parent: Child # 1 Child’s Name Date of Birth In what city and state was this child conceived? City: State: Was this child born at full term? Yes �� No �� If no, at how many weeks was this child born? Name of Alleged Absent Parent I certify that Child #1 listed above was conceived as a result of sexual intercourse with the alleged parent l have listed at the location I listed above. Signature: Paternity Established? Voluntary Support Court-Ordered Child Support Has paternity been established? Date you last received money Yes �� No �� from the Absent Parent If so, by what means? Court City, State Date ordered Amount ordered More Information about Absent Parent Last Known Address Telephone Social Security Number Alias or Nicknames Birthdate Race Place of Birth (City, State) Last Known Place of Employment Dates of Employment: Name of Absent Parent’s Father Name of Absent Parent’s Mother Child with Absent Parent: Child # 2 Child’s Name Date of Birth In what city and state was this child conceived? City: State: Was this child born at full term? Yes �� No �� If no, at how many weeks was this child born? Name of Alleged Absent Parent I certify that Child #2 listed above was conceived as a result of sexual intercourse with the alleged parent l have listed at the location I listed above. Signature: December 2015 5 of 8


18867TPe
To see the actual publication please follow the link above