DOMESTIC RELATIONS INFORMATION SHEET
THIS SECTION FOR OFFICAL USE ONLY
Case number: ________________ Assigned judge: ______________________

The following information is required by New Mexico law and federal law for child support enforcement. The information also is needed to identify and keep up with your case. If child support is not paid, this information will help the court get the money for your child(ren).
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Information regarding petitioner and respondent.

Petitioner Respondent
Name: Chappelle, Annette K. Name: Chappelle, George T., Jr.
Other names: Couchman (maiden) Other names:
Address: 5580 Bataan Memorial E. #117 Address: 601 W. Delaware St.
City: Las Cruces City: Cleveland
State: New Mexico State: Oklahoma
Zip code: 88011 Zip code: 74020
Phone number: (575) 644-6041 Phone number: (918) 605-9885
Date of birth: 04-02-1959 Date of birth: 08-29-1964
Social Security number: 500-54-4807 Social Security number: 491-06-3678

Parties’ minor children. N/A - No minor children

Name: __________________________ Name: __________________________
Date of birth: _____________________ Date of birth: _____________________
Social Security number: ____________ Social Security number: ____________

Name: __________________________ Name: __________________________
Date of birth: _____________________ Date of birth: _____________________
Social Security number: ____________ Social Security number: ____________

Has any court made an order for child support? ______ Yes _______ No

Has any court changed the amount of child support you requested? ____ Yes ____ No

If you answered “Yes” to either question, what state and what court made the order?
_________________ Court _____________________ State

Request to limit access to information. N/A - No minor children

[ ] I have reason to fear