This form contains 66 fields organized into 18 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
CERTIFICATION
Certifier Name	Text	Please provide the name of the person certifying this statement.
Eighth Child Information
Eighth Child Name and Birthdate	Text	Enter the full name and birthdate of the eighth child.
Eighth Child Court Case Number	Text	Enter the court case number associated with the eighth child.
Eighth Child Period Covered	Text	Enter the period of time covered for the eighth child's care.
Eighth Child Amount Received	Number	Enter the total monetary amount received for the eighth child.
Eleventh Child Information
Eleventh Child Name and Birthdate	Text	Provide the full name and birthdate of the eleventh child.
Eleventh Child Court Case Number	Text	Enter the court case number associated with the eleventh child.
Eleventh Child Period Covered	Text	Indicate the period for which the services for the eleventh child are covered.
Eleventh Child Amount Received	Number	Specify the monetary amount received for the services provided to the eleventh child.
Fifth Child Information
Fifth Child Name and Birthdate	Text	Enter the full name and birthdate of the fifth child.
Fifth Child Court Case Number	Text	Provide the court case number associated with the fifth child.
Fifth Child Period Covered	Text	Specify the period covered for the fifth child's information.
Fifth Child Amount Received	Number	State the amount of money received for the fifth child.
First Child Information
Child's Name and Birthdate	Text	Enter the full name and birthdate of the first child.
Court Case Number	Text	Enter the court case number associated with the first child.
Period Covered	Text	Enter the period for which the services or care were provided for the first child.
Amount Received	Number	Enter the total amount of money received for the first child.
Fourteenth Child Information
Fourteenth Child Name and Birthdate	Text	Enter the full name and birthdate of the fourteenth child.
Fourteenth Child Court Case Number	Text	Enter the court case number associated with the fourteenth child.
Fourteenth Child Period Covered	Text	Enter the period of time for which services were covered for the fourteenth child.
Fourteenth Child Amount Received	Number	Enter the total amount received for the fourteenth child.
Fourth Child Information
Fourth Child Name and Birthdate	Text	Enter the full name and birthdate of the fourth child.
Fourth Child Court Case Number	Text	Provide the court case number associated with the fourth child.
Fourth Child Period Covered	Text	Specify the period during which services were covered for the fourth child.
Fourth Child Amount Received	Number	Enter the total amount of money received for the fourth child during the specified period.
General
Recipient Name	Text	Provide the name of the entity that received the stated monies.
Text3	Text	Max length: 2 characters
Text3	Text	Max length: 2 characters
Monies Received Information
Text2	Text
Year of Payments Received	Text	Enter the year when the payments were received. Max length: 2 characters
Text1	Text
State of Monies Received	Text	Enter the name of the state where the monies were received.
Month of Monies Received	Text	Enter the month when the monies were received.
Ninth Child Information
Ninth Child Name and Birthdate	Text	Provide the full name and birthdate of the ninth child.
Ninth Child Court Case Number	Text	Enter the court case number associated with the ninth child.
Ninth Child Period Covered	Text	Specify the period covered for the services or care provided to the ninth child.
Ninth Child Amount Received	Number	Enter the amount of money received for the ninth child.
Second Child Information
Second Child Name and Birthdate	Text	Enter the full name and birthdate of the second child.
Second Child Court Case Number	Text	Enter the court case number associated with the second child.
Second Child Period Covered	Text	Enter the period covered for which monies were received for the second child.
Second Child Amount Received	Number	Enter the total monetary amount received for the second child.
Seventh Child Information
Seventh Child Name and Birthdate	Text	Provide the full name and birthdate of the seventh child.
Seventh Child Court Case Number	Text	Enter the court case number associated with the seventh child.
Seventh Child Period Covered	Text	Specify the period covered for the seventh child's services.
Seventh Child Amount Received	Number	Indicate the total amount received for the seventh child's services.
Sixth Child Information
Sixth Child Name and Birthdate	Text	Please enter the full name and birthdate of the sixth child.
Sixth Child Court Case Number	Text	Please provide the court case number associated with the sixth child.
Sixth Child Period Covered	Text	Please specify the period covered for the sixth child's services.
Sixth Child Amount Received	Number	Please enter the total monetary amount received for the sixth child.
Tenth Child Information
Tenth Child Name and Birthdate	Text	Enter the name and birthdate of the tenth child.
Tenth Child Court Case Number	Text	Enter the court case number associated with the tenth child.
Tenth Child Period Covered	Text	Enter the period of time covered for the tenth child's services.
Tenth Child Amount Received	Number	Enter the amount of money received for the tenth child.
Third Child Information
Third Child Name and Birthdate	Text	Provide the name and birthdate of the third child.
Third Child Court Case Number	Text	Enter the court case number associated with the third child.
Third Child Period Covered	Text	Specify the period covered for the third child.
Third Child Amount Received	Number	Enter the amount of money received for the third child.
Thirteenth Child Information
Thirteenth Child Name and Birthdate	Text	Enter the full name and birthdate of the thirteenth child.
Thirteenth Child Court Case Number	Text	Enter the court case number associated with the thirteenth child.
Thirteenth Child Period Covered	Text	Enter the period covered for the thirteenth child's care or services.
Thirteenth Child Amount Received	Number	Enter the total amount of money received for the thirteenth child.
Total Received
Total Received	Number	Enter the total amount of monies received.
Twelfth Child Information
Twelfth Child's Name and Birthdate	Text	Enter the full name and birthdate of the twelfth child listed.
Twelfth Child's Court Case Number	Text	Enter the court case number associated with the twelfth child listed.
Twelfth Child's Period Covered	Text	Enter the period for which the services or support were covered for the twelfth child listed.
Twelfth Child's Amount Received	Number	Enter the total amount of money received for the twelfth child listed for the specified period.

Statement of Monies Received for Child(ren) Instructions