WAP Application v2014

WeAreParents Application for Services

First Name
Last Name
Home Address (number and street)
City/State/Zip
Contact Number
Type of Contact Number
Email address
Date of Birth
Social Security Number
Gender		Female Male
I am the
Type of Service(s) Requested		Enforcement/Collections Child Support Assistance Co-Parenting Assistance Paternity Assistance Mediation Joint Custody/Visitation Petition Assistance Modification Service of Process
Time spent w/ child(ren)
Number of Children (for this matter)
Do you currently have a child support order for this matter?		Yes No
Support Ordered Amount (if applicable)
Frequency
Do you receive or pay child support on a regular basis?		Yes No
Last Payment Paid or Received
Do you currently have a visitation, custody and/or a joint custody order for this matter?		Yes No
What jurisdiction (city/state) was the order established?
Is the order part of a divorce decree?		Yes No
Do you have a copy of the court order? (if applicable)		Yes No
Have you or the other parent ever received AFDC, TANF, TCA or any other type of monetary assistance from the state?		Yes No
How do you receive or pay child support? (if applicable)

Child 1
Child Name
Child Date of Birth
Lives with
Gender		Female Male
Current Child Support Arrangement

Child 2
Child Name
Child Date of Birth
Lives with
Gender		Female Male
Current Child Support Arrangement

Child 3
Child Name
Child Date of Birth
Lives with
Gender		Female Male
Current Child Support Arrangement

Name of Other Parent
Date of Birth
Contact Number
Type of Contact Number
Employer Address
Type of Industry/Field
Relationship with other parent		Cordial Stable Good Not Good Problematic Confrontational

What is your preferred method of contact?
How did you hear about us?		Google Search Engine Referred by Individual Referred by Agency Direct E-mail Courthouse Church Other
Please upload any documents (court order, child support/court notices, MVA license suspension referrals, other) that may be useful for us to assist with your matter.
Please share any additional information.