STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
SUPPORT QUESTIONNAIRE
Instructions: FOR COUNTY USE ONLY
You must answer ALL questions. CWD CASE NAME LCSA CASE NAME
COMPLETE ONE FORM FOR EACH NONCUSTODIAL ALEXSIA VANEGAS
PARENT OR EACH UNMARRIED FATHER IN THE CWD CASE NUMBER LCSA CASE NUMBER
HOME. L1505D0
CWD WORKER NAME/NO. LCSA WORKER NAME/NO.
Use ink. Print answer. Check Yes, No, or Unknown. Srboui Aladzhyan 19DP820C0J
Use a separate piece of paper if you need more room. TELEPHONE NUMBER TELEPHONE NUMBER
(818) 718-5127
SECTION 1 - COMPLETE THE FOLLOWING ABOUT YOURSELF
NAME (FIRST, MIDDLE, LAST) MAIDEN NAME
ALEXSIA D VANEGAS
HOME ADDRESS (STREET NUMBER AND NAME, APARTMENT NUMBER, IF ANY) CITY STATE ZIP TELEPHONE NUMBER
8721 OWENSMOUTH AVE APT 10 CANOGA PARK, CA 91304-2412 (818) 213-6059
SOCIAL SECURITY NUMBER (SSN) BIRTHDATE BIRTH PLACE RACE
xxx-xx-0960 02/02/2000 United States Mexican
YOUR RELATIONSHIP TO CHILDREN YOUR RELATIONSHIP TO NONCUSTODIAL PARENT/UNMARRIED FATHER IN THE HOME
Spouse Ex-Spouse Friend Other
SECTION 2 - COMPLETE THE FOLLOWING ABOUT THE NONCUSTODIAL PARENT OR
UNMARRIED FATHER IN THE HOME
A. NAME (FIRST, MIDDLE, LAST) SOCIAL SECURITY NUMBER (SSN) MALE
Carlos Mendez FEMALE
LAST KNOWN ADDRESS (STREET NUMBER AND NAME, APARTMENT NUMBER, IF ANY) CITY STATE ZIP
WHEN WAS THIS ADDRESS CURRENT? TELEPHONE NUMBER WHEN DID YOU LAST HEAR FROM OR GET MAIL FROM THIS PARENT? Does this Parent Yes
live with you? No
BIRTHDATE BIRTH PLACE HEIGHT WEIGHT EYE COLOR HAIR COLOR RACE
Mexico 5’9 180 BROWN Brown Mexican
SCARS, BIRTHMARKS, TATTOOS, NICKNAMES, ETC.
B. WHAT KIND OF INCOME DOES Unemployment or Disability
Earnings Social Security None Other
NONCUSTODIAL PARENT HAVE? Insurance Benefits
LAST KNOWN EMPLOYER TELEPHONE NUMBER
STREET ADDRESS TYPE OF WORK
CITY STATE ZIP UNION Yes, Union Name No Unknown
MEMBER?
WHEN DID THIS PARENT LAST WORK THERE? UNION ADDRESS:
C. DOES THIS PARENT HAVE HEALTH Yes No WHO IS COVERED?
INSURANCE FOR THE CHILDREN? Unknown
NAME OF INSURANCE POLICY NUMBER DATE OF COVERAGE
D. PARENTS ARE MARRIED DATE DIVORCED DATE SEPARATED NEVER MARRIED
OR HAVE BEEN WHERE WHERE LIVING TOGETHER
1st Copy – Local Child Support Agency 2nd Copy – County Welfare Department 3rd Copy – Applicant
CW 2.1 (Q) (10/16) SUPPORT QUESTIONNAIRE REQUIRED FORM–SUBSTITUTE PERMITTED
0000000452992732
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
E. IS THERE A COURT ORDER FOR SUPPORT? AMOUNT ORDERED HOW OFTEN?
Yes No Pending $
DATE OF COURT ORDER COURT ORDER NUMBER LOCATION OF COURT (COUNTY & STATE)
How does the parent pay? Pays Household Bills To You WHEN DID PARENT LAST PAY? HOW MUCH?
To County Payroll Deduction Other $
F. NAME OF A FRIEND OR RELATIVE OF NONCUSTODIAL PARENT RELATIONSHIP TO NONCUSTODIAL PARENT TELEPHONE NUMBER
ADDRESS(NUMBER AND STREET) CITY STATE ZIP
G. Does this parent own any motor vehicles? MAKE MODEL YEAR LICENSE NO. STATE
Yes No Unknown
H. Does this parent own a house, land, buildings, or bank accounts? WHAT/WHERE
Yes No Unknown
I. Is this parent currently on probation or parole? WHAT COUNTY OR STATE?
Yes No Unknown
J. Has this parent ever been in jail or prison? IF YES, WHEN/WHERE?
Yes No Unknown
K. Has this parent ever been in the military? IF YES, WHEN/WHAT BRANCH?
Yes No Unknown
L. Are you able to identify or locate the noncustodial parent?
Yes No
SECTION 3 - CHILDREN (IN YOUR HOME) OF THIS PARENT OR UNMARRIED FATHER PATERNITY DECLARATION
YES UNK
NAME OF CHILD
XM
SSN BIRTHDATE BIRTHPLACE, CITY, STATE X NO
DATE SIGNED COUNTY
Mateo Vanegas F
NAME OF CHILD SSN BIRTHDATE BIRTHPLACE, CITY, STATE YES NO UNK
M
DATE SIGNED COUNTY
F
NAME OF CHILD SSN BIRTHDATE BIRTHPLACE, CITY, STATE YES NO UNK
M
DATE SIGNED COUNTY
F
NAME OF CHILD SSN BIRTHDATE BIRTHPLACE, CITY, STATE YES NO UNK
M
DATE SIGNED COUNTY
F
SECTION 4 - SUPPORT ENFORCEMENT SERVICES (MEDI-CAL ONLY)
I don't want other child support enforcement services.
I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE UNITED STATES OF AMERICA AND THE STATE OF
CALIFORNIA THAT THE INFORMATION IN THIS QUESTIONNAIRE IS TRUE, CORRECT AND COMPLETE.
SIGNATURE DATE
1st Copy – Local Child Support Agency 2nd Copy – County Welfare Department 3rd Copy – Applicant
CW 2.1 (Q) (10/16) SUPPORT QUESTIONNAIRE REQUIRED FORM–SUBSTITUTE PERMITTED
0000000452992732
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