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E this form and return it to the Division of Child Support (DCS) at the address listed on page 4. Except for your signature, print your responses in blue or black ink only. Information About Me NAME (FIRST, MIDDLE, LAST) TELEPHONE NUMBER ( STREET ADDRESS SOCIAL SECURITY NUMBER ) CITY STATE ZIP CODE Information About the Noncustodial Parent NAME (FIRST, MIDDLE, LAST) Payments I understand that DCS can send support payments to me by Electronic Funds Transfer (EFT) by depositing the payment.

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