Fill and Sign the Affidavit of Child Support Payments Received Form

*03EN002E-001* *03EN002E-001* OKLAHOMA DEPARTMENT OF HUMAN SERVICES Affidavit of Child Support Payments Received Office use only Court case no.: OK IV-D case no.: Custodial person name Noncustodial parent name Child's name Child's date of birth Child's name Child's date of birth Child's name Child's date of birth 1. I, , state that child support in the amount of $ per month is due from 2. I, , have received no child support from the noncustodial parent. Do not fill out the remainder of the form. Please sign and date the form. OR 3. I, , have received child support payments from the noncustodial parent as shown below. List all child support payments below. Month Year: Jan $ Feb $ Mar $Apr $ May $ Jun $July $ Aug $ Sep $Oct $ Nov $ Dec $ Month Year: Jan $ Feb $ Mar $ Apr $ May $ Jun $ July $ Aug $ Sep $ Oct $ Nov $ Dec $ Month Year: Jan $ Feb $ Mar $Apr $ May $ Jun $July $ Aug $ Sep $Oct $ Nov $ Dec $ OKDHS issued 7-1-2007 03EN002E (CSED-1-A) Page 1 of 3 03EN002E (CSED-1-A) Affidavit of Child Support Payments Received Page 2 of 3 OKDHS issued 7-1-2007 03EN002E (CSED-1-A)Affidavit of Child Support Payments Received Month Year: Jan $ Feb $ Mar $Apr $ May $ Jun $July $ Aug $ Sep $Oct $ Nov $ Dec $ Month Year: Jan $ Feb $ Mar $Apr $ May $ Jun $July $ Aug $ Sep $Oct $ Nov $ Dec $ Month Year: Jan $ Feb $ Mar $Apr $ May $ Jun $July $ Aug $ Sep $Oct $ Nov $ Dec $ 4. The following is an explanation regarding the period(s), if any, for which support may be due but no request is being made to collect: I state under penalty of perjur y under the laws of Oklahoma that the foregoing is true and correct. Signature of custodial person Date and place Mail this form to your Oklahoma Departm ent of Human Services (OKDHS) county office. The OKDHS county offi ce forwards Form 03EN002E to the appropriate OKDHS Child Support Enforcement Division (CSED) district office. Page 2 of 3 OKDHS issued 7-1-2007 Affidavit of Child Support Payments Received 03EN002E (CSED-1-A) OKDHS issued 7-1-2007 Page 3 of 3 Affidavit of Child Support Payments Received 03EN002E (CSED-1-A) Purpose of form Form 03EN002E is completed, signed, and dated by the custodial person in order to proceed with the process of es tablishing and enforcing child support orders. Depending upon the circumstances, Form 03EN002E may not be the only form required to establish and enforce child support orders. Instructions 1. Use a black ink pen to complete Form 03EN002E. 2. Complete statement number 1 ch ild support has been ordered against a noncustodial parent. 3. If you have notreceived child support from the no ncustodial parent, complete statement number 2 and do not fill out the remainder of the form. Please sign and date the form. Return the original Form 03EN002E to the Oklahoma Department of Human Services (OKDHS), Family Support Services (FSS) intake worker. The FSS intake worker forwards Form 03EN002E to the appropriate OKDHS Child Support Enforcement Division (CSED) district office. 4. If you have received child support from the noncustodial parent, complete statement number 3 and start with the most recent y ear you received child support or were given a judgment for lack of support, and work back. Please sign and date the form. Return the original Fo rm 03EN002E to the FSS inta ke worker. The FSS intake worker forwards Form 03EN002E to the ap propriate OKDHS CSED district office. Write in only payment amounts for child support and spousal supp ort (alimony). 5. If Form 03EN002E is not completed at the time of application for services, it must be completed and re turned within ten days of the notice of certification for services. OKDHS issued 7-1-2007 Page 3 of 3