LOCATE DATA SHEET

_____________________________________

Petitioner IV-D Case: [ ] TANF
    [ ] IV-E Foster Care
    [ ] Medicaid Only
Respondent   [ ] Former Assistance
    [ ] Never Assistance
      File Stamp

To: (Central Registry or Agency Name and Address)


From: (Contact Person, Agency, Address, Phone, Fax, E-mail)

Initiating FIPS Code __________________ State __________________________
Initiating IV-D Case No. _______________________________________________
Initiating Tribunal No. _________________________________________________



[ ]Non Custodial Parent Information [ ]Custodial Parent Information [ ]Possibly Dangerous

Full Name (First, Mid, Last) Social Security Number(s)

[ ] Alias
[ ]Maiden Name
Mother's Maiden or Father's Name
Current Spouse's Name (Fst. M, Lst)

Date of Birth(or approximate year) Place of Birth (City, State, County) Driver's License Number/State

Sex
Race
Hair
Eyes
Height
Weight
Distinguishing Marks, Scars, Tatoos, Glasses, Etc.

Last Known Address - [ ] Residence [ ] Mailing [ ] Confirmed Date: ___________
Telephone: ( )______________________

Usual Occupation/Professional Licenses:

Last Known Employer (Name, Full Address, Federal EIN) Confirmed Date________________
Telephone: (_____)_________________

Other Information, Including Assets, Education, Police Record, Public Assistance History
Employment
Wage Qtr ________________
Wage Year______________
Wage Amount ____________
Attachments: [ ] Photograph [ ]Other Items, e.g. Fingerprints

________________
____________________________
_________________________
Date
Initiating Contact Person (Print or Type)
Telephone Number and Extension

Fax Number:______________

E-mail:______________________________

 

 

Locate Data Sheet (OMB No. 0970 - 0085)