How many dependent children are living in your family household?
If married, are
both
you and your spouse employed 30 or more hours weekly or full-time students?
Yes
No
If single, are you employed 30 or more hours weekly or a full-time student?
Yes
No
First child's full name
Child's Birthday
1
2
3
4
5
6
7
8
9
10
11
12
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2002
2003
2004
2005
2006
2007
2008
2009
2010
Age
Sex
M
F
Child resides with
Mother
Father
Both Parents
Other
Second child's full name
Child's Birthday
1
2
3
4
5
6
7
8
9
10
11
12
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2002
2003
2004
2005
2006
2007
2008
2009
2010
Age
Sex
M
F
Child resides with
Mother
Father
Both Parents
Other
Mother's name
Married
Single
Home phone
Work phone
Cell phone
Email
Mailing address
City
Zip
Wages earned
per week
Hours worked
per week
Annual Wages
Child support/alimony you receive
per month
If student:
Full Time
Part time
Father's name
Married
Single
Home phone
Work phone
Cell phone
Email
Mailing address
City
Zip
Wages earned
per week
Hours worked
per week
Annual Wages
Child support/alimony you receive
per month
If student:
Full Time
Part time
