Fill and Sign the Brand Authorization Letter Format Word

APPLICATION FOR TITLE IV-D CHILD SUPPORT SERVICES (page 1) State Form 34882 (R6/l2-92) DFC Form 425A Complete one application for each absent parent fOI· whom application is made. PlUVACY STATEMENT CHILD SUPPORT BUREAU Division of Family and Children Family & Social Services Administration 402 W. Washington SI. Rm. W360 Indianapolis, IN 46204 The records in this series are confidential according to 45 CFR 303.21. This agency is requesting disclosure of personal information that is necessary to accomplish the statutory purpose of the agency according to 45 CFR 303.70. Disclosure of this information is mandatory. Failure to provide any information may prevent this form from being processed. INSTRUCTIONS (please read) The Indiana Child Support Bureau offers child support services to persons desiring to obtain child support from a responsible parent outside the home. These services are: Complete Service or Parent Locator Only Service. ALL FEES FOR SERVICES ARE NONREFUNDABLE. MONEY ORDER IN THE AMOUNT OF $25.00 IS TO BE MADE PAYABLE TO DIVISION OF FAMILY AND CHILDREN (CASH OR CHECKS ARE NOT ACCEPTED) CALL 812 268-6008 TO SCHEDULE AN APPOINTMENT AFTER FORM IS COMPLETED COMPLETE SERVICE: The applicant will be entitled to all services offered by the IV -D program as long as the case remains active. This service shall include the Parent Locator Service and the legal services ofthe local IV -0 agency. These services include Establishing Paternity, Establishing andlor Enforcing a support obligation (including health insurance coverage). The complete service does NOT include handling a divorce case, enforcement of custody or visitation provisions, nor matters other than those associated with the support of dependent children. All support payments may be directed to the State for monitoring and disbursement. ANY COSTS INCURRED IN EXCESS OF THE APPLICATION FE, SUCH AS COURT COSTS, WITNESS FEES, BLOOD TEST COSTS, IRS INTERCEPT FEES AND ADMINISTRATIVE COSTS ASSOCIATED WITH THIS CASE MAY BE CHARGE AGAINST THE APPLICANT, In addition the Tax Refund Intercept Project may be used to collect child support arrearages, Application for Complete service does not guarantee, however, that your case will be submitted for tax refund intercept nor that tax refund monies will be collected. In order to certify a case for intercept, there must be a valid child support order, the absent parent must be at least $500 in arrears, and the applicant must have the absent parent's Social Security number. If any children of the absent parent have received TANF/AFDC in the past, any collection made from an intercept will first be applied by the State to any unreimbursed public assistance on any former TANP/AFDC case. Ifthe IRS, for any reason, reclaims all or any portion of an intercepted refund that has already been paid to you, you are obligated to repay the State of Indlana the amount reclaimed by the IRS, You authorize that any such repayment may be deducted from support collected on your behalf if other arrangements have not been made and fulfilled. PARENT LOCATOR SERVICE: The applicant will be entitled to all resources offered by the State and Federal Parent Locator Service until a verified address is provided or all sources for location are exhausted. The payment of the application fee does not guarantee a successful location. The success will greatly depend on the applicant's own knowledge about the absent parent. If all sources of information are exhausted without a successful location, the applicant will be notified. Upon notification, the applicant will have six months to provide additional information if no additional information is provided within the six month period, the case wi!! be closed and the applicant notified. TERMINATION OF SERVICES: The applicant may terminate services only if any charges due or overpayments owing are paid, by notifying the Child Support Bureau in writing that services are no longer desired. The State may terminate services only in accordance with 45 CPR 303.11. Services in respect to this application will also terminate if the applicant receives TANF/AFDC. APPLICANT'S OBLIGATIONS: The applicant is expected to fully cooperate with the local IV-D agency in the legal and non-legal preparation of the case, including, but not limited to notifying the local IV -D agency of change of address, supplemental information regarding the absent parent, reuniting with the absent parent, and other information pertinent to the case. THE APPLICANT MUST ALSO NOTIFY THE CHILD SUPPORT BUREAU AT THE ABOVE ADDRESS OF ANY CHANGE OF ADDRESS, THE CLERK OF COURT WHERE THE ORDER EXISTS MUST ALSO BE NOTIFIED IN WRITING. APPLICANT'S STATEMENT I affirm that the information in this application is true and correct and that false information could result in Perjury charges against me. I understand that I am to cooperate with the local IV-D agency in order for my case to be processed, and non-cooperation can result in termination of my case. I further understand that payment ofthe application fee does not guarantee successful action on the case but rather all reasonable attempts, will be made in my behalf to obtain successful results for the service requested, I have read and understand the above NOTICE. I hereby request the following service under the terms outlined above. _Complete Service _Parent Locator Service Only Signature of applicant Application taken by Page 1 of4 Date signed (rno/day/yr) Fee paid Case number IFORMOOOI APPLICATION FOR TITLE IVMSCHILD SUPPORT State Form 34882 (R6f12-92) DFC Form 425A SERVICES (page 2) =----=-=----=- To be completed by County OJ11ce _ Case Number PART II: APPLICANT l. Full name ofapplieant (last, first and middle initial) 2. Date of birth (mo/day/yr) 3. Address of applicant (street and number or rural route number) 4. Maiden City State My mailing address is: ___ Social Security number Race Sex Apt. or room number Zip code Same as above ___ Different (print below) Mailing address (street and number or rural route number) Apt. or room number City Zip code State 5. Telephone number (home) 6. Address of other person who will always know my whereabouts: 7. DATA Telephone number (work) Name Telephone number Address (street, city, slate, ZIP code) Relationship If "Yes" give the month and year of the Iast cheek Have you ever received an AFDC In Indiana? __ Yes __ No PART III: I wish to secure support payments CHILD'S FULL NAME (Last, first, middle initial) 011 The County your case was in DEPENDENT Welfare check DATA behalf of the following children. SEX BIRTHDATE PLACE OF BIRTH SOCIAL SECURITY NUMBER (mo/day/yr) RELATIONCHIP TOME 1. 2. 3. 4. 5. 6. Parent Locator Service For this absent parent I desire: ___ Complete Service PART IV: ABSENT PARENT DATA Alias or maiden name (last, first, middle) A. Pull name of absent parent (last, first, middle) Social Security number Date of birth Age Place of birth (city and state) Race Height Weight Hair Street name and number or rural route Humber B. Absent parent's address and telephone numbcrts) _Current ~Last known ~ (years) City Page 2 of4 Eyes State Zip code IFORMOOOl APPLTCAnON FOR TITLE IV-D CHILD SUPPORT SERVICES (page 3) State Form 34882 (R6/12-92) DFC form 425A To be completed by County Office _~ __ ~~:-=:---:- _ Case Number C. Employer's address ~Current _Last known _ Name of employer Street name and number or rural route num ber City State Usual type of work D. Marital status of children's parents _Married _._Deserted _Divorced _Never married _Separated ~Unknown Date married Location married Date separated or divorced Lccat ion separated or di vorced (years) E. Complete if parent: _Is currently Branch of service _Army _Navy Rank ~Omcer Enlisted G. Prior arrest record _Or has been in the military services _Marines _Air Force _Coast Guard Service nllmber~~ _ Where ~Yes _No The absent parent _is currently _has Name of institution Date F. Names of the absent parent's children. (check blank in front of name if there is "NO" support order for this child) 1.. _ _2 .. _ ~ 3. been in the past injail, prison or institution Date sentenced Address (city, state or county) ~ _ ~4. ~ _5 .. _ Date released H. Absent parent's father's name _6., Address (city, state or county) _ Telephone Verification and comments I. Absent parent's mother's maiden name Address (city, state or county) Telephone I. Other contact person for absent parent/name and relationship Address (city, state or county) Telephone J. COMPLETE THIS SECTION IF CHILD IS BOHN OUT OF WEDLOCK (Place all other paternity information in comment section) Has paternity suit been filed? Yes No Date Place~------------------- (if yes, please provide copy of order and birth certificate, ifno, additional forms need completed) Has paternity been established? By court order? ~Yes _No ~Yes Amount S Datc'-- No _ Has parent ever paid support or mcd ical or bought thi ngs for children? - Yes ~ No Frequency K. COURT DATA (all applicants must complete this section) Has parent ever been ordered by II court to pay support for these children? _Yes _No Name of Court If''No'', has a petition been filed and a haring pending? Address of court Cause number of court order Amount $ Absent parent paying support ~ _Yes _No Frequency Yes - No To whom does parent pay support? Date last paid Is parent paying military allotment? _Yes _No Amount $ TO BE COMPLETED BY COUNTY OFFICE Application taken b)': Page 3 of4 Date (mo/day/yr) IFORI\10001 APPLICA nON FOR TITLE IV·D CHLD SUPPORT SERVICES (page 4) State Form 34882 (R6/12·92) DFC Form 425 A To Be completed by County Office __ -=-_::-:-~ _ Case Number ASSIGNMENT FOR COLLECfION FOR PERSONS NOT RECEIVING PUBLIC ASSISTANCE N arne of absent parent CHILDREN'S NAMES I. 5. 2. 6. 3. 7. 4. 8. AGREEMENT I understand and agree that support payments collected hereafter from the absent parent names above on behalf of mysel f andlor the above named children Will be paid to the Division of Family and Children, Family and Social Services Administration, and that said support payments will be paid to me by the agency after deduction of any charges due and owing to that agency. Such charges are explained in page one of the "Application for Title IY·D Child Support Services" executed by the applicant. This authorization shall continue in effect until terminated ill the manner set forth on page one of the "Application for Child Support Services". Printed name of appJ icant Date signed (mo/day/yr) Signature of applicant Cause number or support order Page-l of q Court name IFOHi\IOOOl