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Username:
Password: Register
Original Case Number:
Atlas Number:
Date of original Order:
Original Case Judge

Is the Department of Economic Security (DES) providing child support enforcement services to at least one of the parties?

Yes
No
Unknown

The petitioner in the original case was?

Father
Mother

This form is being completed by?

Father
Mother

Who currently pays the child support?

Father
Mother

Who do the children live with now?

Father
Mother

How many days of visitation does the non custodial parent get per year?


Father

Name

Address

City

State

Zip

Phone

DOB

SSN

Job Title

Current Employer

Payroll Address

City, State, Zip

Telephone

Fax

Mother

Name

Address

City

State

Zip

Phone

DOB

SSN

Job Title

Current Employer

Payroll Address

City, State, Zip

Phone

Fax



Enter the following amounts from the current support order:

Child Support

per

Spousal Maintenance

per

Other

per

Payments in arrears:

per



Please enter current monthly income and expenses:


These must be monthly figures:
Father
Mother

Gross income

Income is Estimated or Attributed?

Spousal Maintenance paid

Spousal Maintenance received

Child Support paid(other children)

Adjustment for Other Children

Medical Insurance is paid by

Work Related child care is paid by

Extraordinary Child Expenses


Please enter information about the minor children, starting with the oldest.:

Name
First M.Last
Gender
DOB
mm/dd/yyyy
SSN
123-45-6789
1)
2)
3)
4)
5)
6)

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