DELAWARE HEALTH
AND SOCIAL SERVICES
Division of Child Support Enforcement


This form is used to change names, addresses and update account information. Please complete all information to assist us in accurately updating your account. PLEASE PRINT ALL INFORMATION.

Current Name: 

Previous:

Date of Birth: 

Soc. Sec.:

Driver's Lic.# 

Current Address:

Previous Address:

Absent Parent:

Soc. Sec.#

Employer:

Children Support is Being Paid For:

Name and Date of Birth

Name and Date of Birth

Name and Date of Birth

Name and Date of Birth

Declaration: I declare under the penalties of perjury that the information given by me on this form is
true and complete to the best of my knowledge.

Case#:

Signature

MCI#:

Date