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Forgiveness of Arrears Program Eligibility Application If you have ever been convicted of criminal non-support or terminated from this program, do not proceed with this application, as you do not qualify. You may qualify for the forgiveness program if: (1) you owe a state debt of at least $1,500; and (2) you owe an ongoing support obligation for children that have not yet emancipated or you owe child support arrears to the other parent; and (a) have been incarcerated for more than one year and have no other means of paying support while incarcerated; or (b) have not actively avoided paying support and currently do not have the ability to pay support as previously ordered. Do not proceed with this application if you do not qualify under the above paragraph. CSSD Case Number: _____________________________ How did you hear about this Program? __________________________________ Are you enrolled with a Community Based Organization? Yes, No (An organization operating a program designed to directly or indirectly address personal or economic factors that may reduce your earning potential or ability to pay support.) Types of programs may be: 1. 2. 3. 4. Parenting Plans Drug and alcohol treatment programs Job an vocational training programs Programs offered through a state agency for any of the above mentioned Name: _________________________ SSN1 _________________ DOB: ___________ Acceptance into this program constitutes an application for services by the obligor parent. __________________ Date ____________________________ Printed Name ____________________________ Signature 1 The disclosure of your social security number on this form is voluntary. We will use it to assist us in identification. CSSD Form 04-2400A (Rev 02/16/2007)