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Exhibit 1 <br />County of Orange Child Support Enforcement <br />Certification Requirements <br />(blank form) <br />A. In the case of an individual CONTRACTOR, his/her name, date of birth, Social Security <br />number, and residence address: <br />Name: <br />D.O.B: <br />Social Security No: <br />Residence Address: <br />B. In the case of a CONTRACTOR doing business in a form other than as an individual, the <br />name, date of birth, Social Security number, and residence address of each individual who <br />owns an interest of ten (10) percent or more in the contracting entity: <br />Name: <br />D. 0. B: <br />Social Security No: <br />Residence Address: <br />Name: <br />D.O.B: <br />Social Security No: <br />Residence Address: <br />Name: <br />D.O.B: <br />Social Security No: <br />Residence Address: <br />(Additional sheets may be used if necessary) <br />County of Orange Page 2 of 3 City of Santa Ana <br />OC Community Resources Contract # 16-28-0039-RWS-P <br />20A-47 <br />