DHS ORS CSS XAPP
New 1/11/08 Rev 1/18/10
Utah Department of Human Services
Office of Recovery Services/Child Support Services
APPLICATION FOR CHILD SUPPORT SERVICES
INSTRUCTIONS
======================================================================================
1.
Read the “Notice of Services” included with this application. Keep this for your records.
2.
Determine how many applications you must complete. Each “family group” requires a separate
application. For example:
*I have two children with the same father and mother: I need to complete ONE application.
*I am the mother of two children, but each has a different father: I need to complete TWO applications.
*I am the father of three children, but one has a different mother: I need to complete TWO applications.
*I am the mother of one child, but there are two men who could possibly be the father: I need to complete TWO
applications.
* I am taking care of two grandchildren. Each has a different father and mother. I need to complete TWO
applications.
IF YOU HAVE QUESTIONS ABOUT HOW MANY APPLICATIONS TO COMPLETE, PLEASE CALL.
3.
Complete the application for services. Be sure that your application is complete and signed.
Incomplete applications can delay opening your child support case and can delay approval of your cash
assistance or medical assistance. If your application is not complete, you may be requested to submit a
new application and new supporting documents.
4.
Attach COPIES of the following documents.
a.
b.
c.
d.
COPIES of all support orders for these children.
COPIES of each child’s birth certificate if the child was not born in Utah. (If your child(ren) was born
in Utah, ORS/CSS will obtain the birth certificate for you.)
COPIES of paternity establishment documents if paternity has already been legally established for
any of the children. (If paternity was established by a Utah Voluntary Declaration of Paternity,
ORS/CSS will obtain a copy of that document for you.)
A COPY of the death certificate or obituary if either parent is deceased.
DO NOT SUBMIT ORIGINAL DOCUMENTS. KEEP ALL ORIGINAL DOCUMENTS WITH YOUR
PERSONAL RECORDS. ORS/CSS CANNOT BE RESPONSIBLE FOR KEEPING OR RETURNING
ORIGINAL DOCUMENTS.
5.
Mail your completed application and copies of all documents to:
Office of Recovery Services
Child Support Services
PO Box 45033
Salt Lake City, UT 84145-0033
Telephone: (801)536-8500
DHS ORS CSS AI01 12/90 Rev 1/18/10
Page 1
UTAH DEPARTMENT OF HUMAN SERVICES
DHS ORS CSS ANIB
5/90 Rev. 1/11/08
OFFICE OF RECOVERY SERVICES / CHILD SUPPORT SERVICES (ORS/CSS)
APPLICATION FOR SERVICES
SECTION I: APPLICANT INFORMATION
1. Your First Name
Your Middle Name
Your Last Name
2. Your Date of Birth mm/dd/yyyy
3. Your Social Security Number
4. Your Relationship to the Children
5. Are YOU the mother or the father of the children listed on this application?
Yes
If "Yes," skip to "Section II: Release of Information."
No
If "No," continue with the questions below.
6. Your Address
Apt #, Bsmt, etc.
City
State
7. Your Home Telephone Number
ZIP Code
Country
8. Other Telephone Number (Cell/Pager/Work)
9. Do you have a document or court order that gives you the right to collect support from either of the parents for these children? (For example, do
you have a temporary custody order or a Juvenile Court order?)
Yes
If "Yes," YOU MUST ATTACH A COPY OF THE ORDER.
No
SECTION II: RELEASE OF INFORMATION
Your case information will be released as follows:
To the Federal Case Registry, where it may be accessed by other state agencies;
To the Attorney General's Office, if your case is referred for a court action;
To the Office of Administrative Hearings, if your case is referred for a hearing;
To another state, if your case is referred to another state's child support agency; or,
To the other party or the other party's attorney, if we receive a written request and a parent-time order. If a request is made for your
address and the address of your child(ren), you will be sent a notice that gives you an opportunity to contest the release of your
information.
10. If you have a domestic violence issue, would you like ORS/CSS to attempt to safeguard your case information and your child(ren)'s case
information?
No
Yes
If "Yes," YOU MUST PROVIDE ORS/CSS WITH ONE OF THE FOLLOWING:
a protective order, a current court order prohibiting disclosure, a current court order
limiting or prohibiting the requested person's contact with the party whose location is
being sought, a criminal order, or documentation of a pending action for any of the
above.
SECTION III: GOOD CAUSE
If you have applied for cash assistance and/or Medicaid, you are required to cooperate with the Office of Recovery Services to establish paternity
and to establish and collect child support and medical support.
You may file a "good cause" action at the Department of Workforce Services (DWS) if you fear that emotional or physical harm will come to you or
your child as a result of cooperating with ORS/CSS. "Good cause" is only an option if you have applied for cash assistance and/or Medicaid.
Otherwise, see Section II for information about "Safeguarding."
DWS will review your claim and determine if you qualify for an exception to the cooperation requirements.
YOU MUST PROVIDE YOUR CASEWORKER AT DWS WITH DOCUMENTATION THAT SUPPORTS YOUR REQUEST FOR GOOD CAUSE.
IF YOU FAIL TO PROVIDE THE REQUIRED INFORMATION, YOUR REQUEST FOR "GOOD CAUSE" MAY BE DENIED.
If you claim "Good Cause":
*ORS/CSS WILL OPEN A CHILD SUPPORT CASE UNTIL DWS NOTIFIES ORS/CSS WHETHER YOUR "GOOD CAUSE" CLAIM HAS
BEEN APPROVED OR DENIED.
*YOU MUST STILL COMPLETE THE REST OF THIS APPLICATION WHILE YOUR CLAIM IS REVIEWED.
If you wish to claim "good cause" for refusal to cooperate because you fear that emotional or physical harm will come to yourself or your
child(ren) as a result of cooperating with ORS/CSS, YOU MUST CONTACT YOUR CASEWORKER AT THE DEPARTMENT OF WORKFORCE
SERVICES TO SUBMIT A REQUEST FOR GOOD CAUSE AND TO REQUEST AN AGENCY DECISION FROM DWS BASED ON THE EVIDENCE
THAT YOU PROVIDE AND/OR AN INVESTIGATION.
PAGE
ORS USE:
TEAM *99 (MAIL INTAKE)
OR999
2
SECTION IV: MOTHER'S INFORMATION
11. Mother's First Name
Mother's Middle Name
Mother's Last Name
12. Mother's Maiden Name
13. Mother's Current Marital Status
14. Current Spouse/Significant Other's Name
15. Mother's Social Security Number
16. Mother's Date of Birth (MM/DD/YYYY)
17. Mother's Age
18. City of Birth
19. State of Birth
20. Country of Birth
21. Is the mother deceased?
Date of Death
No
Yes
City and State of Death (include Country if not United States)
If "Yes":
*YOU MUST PROVIDE A DEATH CERTIFICATE OR OBITUARY AS VERIFICATION
22. Height
24. Hair Color
23. Weight
27. Driver's License Number and State
25. Eye Color
26. Race
28. Identifying Marks (scars, birthmarks, tattoos, etc.)
29. Other names, nicknames or aliases the mother has or may be using.
30. Mother's Home Telephone Number
31. Mother's Other Phone Numbers (Cell, Pager)
32. Mother's Residential Address
Apt #, Bsmt, etc.
City
State
ZIP Code
Country
No
33. Is the address listed above located on a Native American Reservation?
Yes
If "Yes," Tribal Affiliation:
34. Mother's Mailing Address (if different)
Apt #, Bsmt, etc.
City
State
ZIP Code
35. Is the mother disabled?
No
Yes
36. Does the mother receive disability benefits?
No
Yes
Country
37. Do the children receive benefits under the mother's disability claim?
38. Has the mother served in the military?
No
Yes
Branch of Service
If "Yes," what type of benefit?
No
Status (Circle One)
Active
If "Yes"
39. Employer Name/Self Employment
Yes
Disabled
Discharged
40. Employer Phone
42. Employer Address
Inactive
Retired
41.Type of Work/Usual Occupation
City
State
ZIP Code
Country of Employer
State of Arrest
Date of Arrest
44. Mother's Mother: First Name
Middle Name
Last Name
45. Mother's Father: First Name
Middle Name
Last Name
43. Has the mother ever been arrested?
No
Yes
If "Yes"
PAGE
3
SECTION V: FATHER'S (OR ALLEGED FATHER'S) INFORMATION
46. Father's First Name
Father's Middle Name
Father's Last Name
47. Father's Current Marital Status
48. Current Spouse/Significant Other's Name
49. Father's Social Security Number
50. Father's Date of Birth (MM/DD/YYYY)
51. Father's Age
52. City of Birth
53. State of Birth
54. Country of Birth
55. Is the father deceased?
Date of Death
No
Yes
City and State of Death (include Country if not United States)
If "Yes":
*YOU MUST PROVIDE A DEATH CERTIFICATE OR OBITUARY AS VERIFICATION
56. Height
57. Weight
58. Hair Color
59. Eye Color
60. Race
62. Identifying Marks (scars, birthmarks, tattoos, etc.)
61. Driver's License Number and State
63. Other names, nicknames or aliases the father has or may be using.
64. Father's Home Telephone Number
65. Father's Other Phone Numbers (Cell, Pager)
66. Father's Residential Address
Apt #, Bsmt, etc.
City
State
ZIP Code
Country
No
67. Is the address listed above located on a Native American Reservation?
Yes
If "Yes," Tribal Affiliation:
68. Father's Mailing Address (if different)
Apt #, Bsmt, etc.
City
State
ZIP Code
69. Is the father disabled?
No
Yes
70. Does the father receive disability benefits?
No
Yes
Country
71. Do the children receive benefits under the father's disability claim?
72. Has the father served in the military?
No
Yes
Branch of Service
If "Yes," what type of benefit?
No
Status (Circle One)
Active
If "Yes"
73. Employer Name/Self Employment
Yes
Disabled
Discharged
76. Employer Address
Inactive
Retired
75.Type of Work/Usual Occupation
74. Employer Phone
State
City
ZIP Code
Country of Employer
77. Has the father ever been arrested?
State of Arrest
Date of Arrest
78. Father's Mother: First Name
Middle Name
Last Name
79. Father's Father: First Name
Middle Name
Last Name
No
Yes
If "Yes"
PAGE
4
SECTION VI: CHILDREN'S INFORMATION
On this page, list ALL of the children born to the mother AND father/alleged father listed on this application . If paternity has not
been legally established and any of the children have or could have a different father, you must complete a separate application with
that man's information. Use an additional page if needed. If you indicate that paternity has been legally established for any
child(ren), YOU MUST ATTACH A COPY OF THE PATERNITY ORDER or OTHER DOCUMENTATION.
80. Child's First Name
Gender
Middle Name
Date of Birth (mm/dd/yyyy) Social Security Number
Mother
This child lives with:
Father
Last Name
City of Birth
Other
State
Country
If other, relationship to child:
Were the mother and father married WHEN THIS CHILD WAS BORN?
Yes
No
IF NO:
City, State (and Country if not U.S.A.) of Conception
Has paternity been legally established?
Yes
No
Could any man other than the man on this application be the father of this child?
No
81. Child's First Name
Gender
Yes
If yes, list names of ALL other possible fathers:
Middle Name
Date of Birth (mm/dd/yyyy) Social Security Number
Mother
This child lives with:
Father
Last Name
City of Birth
Other
State
Country
If other, relationship to child:
Were the mother and father married WHEN THIS CHILD WAS BORN?
Yes
No
IF NO:
City, State (and Country if not U.S.A.) of Conception
Has paternity been legally established?
Yes
No
Could any man other than the man on this application be the father of this child?
No
82. Child's First Name
Gender
Yes
If yes, list names of ALL other possible fathers:
Last Name
Middle Name
Date of Birth (mm/dd/yyyy) Social Security Number
Mother
This child lives with:
Father
City of Birth
Other
State
Country
If other, relationship to child:
Were the mother and father married WHEN THIS CHILD WAS BORN?
Yes
No
IF NO:
City, State (and Country if not U.S.A.) of Conception
Has paternity been legally established?
Yes
No
Could any man other than the man on this application be the father of this child?
No
83. Child's First Name
Gender
Yes
If yes, list names of ALL other possible fathers:
Middle Name
Date of Birth (mm/dd/yyyy) Social Security Number
Mother
This child lives with:
Father
Last Name
City of Birth
Other
State
Country
If other, relationship to child:
Were the mother and father married WHEN THIS CHILD WAS BORN?
Yes
No
IF NO:
City, State (and Country if not U.S.A.) of Conception
Has paternity been legally established?
Yes
No
Could any man other than the man on this application be the father of this child?
No
Yes
If yes, list names of ALL other possible fathers:
PAGE
5
SECTION VII: MARRIAGE & ORDER INFORMATION
***YOU MUST SUBMIT COPIES OF ALL PATERNITY ORDERS, DIVORCE DECREES, AND ANY OTHER
CHILD SUPPORT ORDERS WITH THIS APPLICATION***
Yes
84. Were the mother and father on this application ever married to each other?
If "Yes"
Marriage Date (mm/dd/yyyy)
No
City, County and State of Marriage (include Country if not United States)
(If married to each other more than
once, provide all dates.)
Yes
Did the mother and father ever live together in Utah during the marriage?
Yes
85. Has legal action for separation or divorce been started?
No
No
Yes
Completed?
Divorce Date (mm/dd/yyyy)
No
City, County and State of Divorce (include Country if not United States)
Civil Number of Divorce
If "Yes" to either:
Attorney Name/Phone Number
86. Do other support orders exist for the children on this application (paternity orders, temporary orders, or any other type of order)?
Yes
No
Order Date (mm/dd/yyyy)
City, County and State of Order (include Country if not United States)
Civil Number of Order
If "Yes"
Attorney Name/Phone Number
IF MORE THAN ONE ORDER EXISTS, LIST THE ABOVE INFORMATION FOR ALL ORDERS ON A SEPARATE PAGE.
Yes
87. Have any of the support orders ever been modified?
If "Yes"
Modification Date (mm/dd/yyyy)
No
City, County and State of Modification (include Country if not United States)
Yes
88. Have the children on this application ever received cash assistance from any state other than Utah?
If "Yes"
Dates of cash assistance
State
No
Was child support collected?
Yes
No
Yes
No
89. Do you currently have an assignment, agreement, or contract with a private agent (collection agency or private attorney) to collect your child
support?
Name, Address and Phone Number of Agency or Attorney
No
Yes
If "Yes"
SECTION VIII: MEDICAL INSURANCE INFORMATION
90. Are the children currently covered on any HEALTH insurance policy OTHER THAN MEDICAID or CHIP?
If "Yes"
Policyholder's Date of Birth
Policyholder's Name
Policy Number
Insurance Company Address
State
City
ZIP Code
Dental
Vision
Phone Number
Pharmacy
If you are the policyholder, is this insurance policy offered through your employer?
Employer Name
City
Country
Date Insurance Started (mm/dd/yyyy)
Type of Coverage (Circle All that Apply)
If "Yes"
No
Policyholder's Phone Number
Full Insurance Company Name
Medical
Yes
Policyholder's Relationship to Chidlren
Yes
No
Employer Address
State
ZIP Code
Country
Phone Number
IF THE CHILDREN ARE COVERED BY OTHER POLICIES, LIST THE ABOVE INFORMATION FOR EACH POLICY ON A SEPARATE PAGE.
PAGE
6
SECTION IX: STATEMENT OF ARREARS
91. Are you owed past-due child support based on an order?
Yes
No
If "No," sign this page and go to Section X.
If "Yes," complete the following if you have applied for or are receiving cash assistance and past-due support is owed under an
order, or if you would like ORS/CSS to pursue collection of your ordered past-due support.
IF YOU ARE NOT RECEIVING CASH ASSISTANCE, AND THIS PAGE IS INCOMPLETE, OR IS NOT SIGNED AND DATED, ORS/CSS WILL
ONLY ATTEMPT TO COLLECT THE MONTHLY CURRENT SUPPORT AMOUNT. If monthly spousal support is also past due, attach a similar
page with the same information that is requested below.
YEAR:
Amount Due
YEAR:
Amount Due
Amount Paid
YEAR:
Amount Due
JAN
JAN
FEB
FEB
MAR
MAR
MAR
APR
APR
APR
MAY
MAY
MAY
JUN
JUN
JUN
JUL
JUL
JUL
AUG
AUG
AUG
SEP
SEP
SEP
OCT
OCT
OCT
NOV
NOV
NOV
DEC
DEC
Amount Paid
JAN
FEB
Amount Paid
YEAR:
Amount Due
Amount Paid
DEC
YEAR:
Amount Due
YEAR:
Amount Due
Amount Paid
Amount Paid
JAN
JAN
JAN
FEB
FEB
FEB
MAR
MAR
MAR
APR
APR
APR
MAY
MAY
MAY
JUN
JUN
JUN
JUL
JUL
JUL
AUG
AUG
AUG
SEP
SEP
SEP
OCT
OCT
OCT
NOV
NOV
NOV
DEC
DEC
DEC
Sum-certain Judgments (for example, a court order states that "$1000 is owed for child support through 12-31-1995")
Type of Judgment (Circle One)
Dates Included in the Judgment Original Ordered Amount
Balance Due
Child Support Medical Spousal Support Day Care
Child Support Medical Spousal Support Day Care
Child Support Medical Spousal Support Day Care
I ATTEST THAT THE INFORMATION I HAVE PROVIDED ABOUT THE PAST-DUE SUPPORT IS TRUE AND CORRECT TO THE BEST OF MY
KNOWLEDGE. I UNDERSTAND THAT IN ACCORDANCE WITH U.C.A. 62A-11-303.5, IF I KNOWINGLY PROVIDE FALSE OR MISLEADING
INFORMATION, I AM IN VIOLATION OF U.C.A. 76-8-504 AND MAY BE SUBJECT TO PROSECUTION, CASE CLOSURE, OR BOTH.
Signature
Date
PAGE
7
SECTION X: STATEMENTS OF UNDERSTANDING
Mark ALL of the following boxes to indicate that you have read and understand the statements to the
right.
I have read and I understand the Notice of Services provided with this application.
I understand that if a support payment has been incorrectly credited to my account and sent to me, my future support
payments may be decreased by an amount equal to the payment I received in error.
I understand that anyone may deliver to the Office of Recovery Services/Child Support Services (ORS/CSS) all drafts,
checks, money orders, or other negotiable instruments due by any person obligated to provide support. ORS/CSS has the
power of attorney to act in my name endorsing and cashing all drafts, checks, money orders, or other negotiable
instruments received by the Department as support payments.
ASSIGNMENT OF SUPPORT RIGHTS (only applicable if you apply for and receive cash assistance or Medicaid):
I understand that as a condition of receiving public assistance, I have automatically transferred to the Office of Recovery
Services/Child Support Services (ORS/CSS) all monies payable to me or my child(ren) by any person as support, alimony,
or medical support. The monies include the amount past-due and that become due to me or the child(ren). I understand
that I must turn over to ORS/CSS any support or alimony that the noncustodial parent gives to me. This assignment
supersedes (replaces) any agreement I have made with the noncustodial parent(s) that has not been approved by the
court. I understand that if I receive a direct payment of child support, or if I agree to receive payment of support other than
in the court or administratively ordered manner and receive the payments as agreed, I must immediately deliver that
payment, or its cash equivalent, to ORS/CSS.
SECTION XI: REQUEST FOR SERVICES
Select ONLY ONE of the following options:
I have applied for cash assistance and/or Medicaid AND I am applying for child support services and medical
support services from ORS/CSS. I have read, understand and agree to the Statements of Understanding section
above, including the "Assignment of Support Rights."
I have applied for cash assistance and/or Medicaid. I have completed this application for child support services
and medical support services because I am required to do so to be eligible for cash assistance and/or Medicaid,
and I have read, understand and agree to the Statements of Understanding section above, including the
"Assignment of Support Rights;" however, IF I AM DENIED CASH ASSISTANCE AND MEDICAID, I DO NOT WANT
CHILD SUPPORT SERVICES OR MEDICAL SUPPORT SERVICES.
I have ONLY applied for Medicaid assistance AND I DO NOT WANT CHILD SUPPORT SERVICES. Because I am
only applying for Medicaid assistance, I may decline child support services. I understand that if I do not have a medical
support order, I must cooperate with ORS/CSS in establishing a child support and medical support order. I understand
that after the order is established, I may tell ORS/CSS that I do not want child support services and ORS/CSS will only
provide medical support services. I have read, understand and agree to the Statements of Understanding section above,
including the "Assignment of Support Rights."
I have NOT applied for cash assistance or Medicaid. I am applying for child support services AND medical
support services from ORS/CSS. I have read, understand and agree to the Statements of Understanding section
above.
I ATTEST THAT THE INFORMATION I HAVE PROVIDED ON THIS APPLICATION IS TRUE AND CORRECT TO THE BEST OF
MY KNOWLEDGE. I UNDERSTAND THAT IN ACCORDANCE WITH U.C.A. 62A-11-303.5, IF I KNOWINGLY PROVIDE FALSE
OR MISLEADING INFORMATION, I AM IN VIOLATION OF U.C.A. 76-8-504 AND MAY BE SUBJECT TO PROSECUTION, CASE
CLOSURE, OR BOTH.
Signature
Date
Printed Name
Social Security Number
PAGE
8
SECTION XII: APPLICATION CHECKLIST
Double-check the following items to make sure your application is complete.
I have read the "Notice of Services" and removed those pages from this application to
keep for my records.
Complete
Complete
I have completed separate applications for each "family group."
For example:
*I have two children with the same father: I need to complete ONE application.
*I have two children but each has a different father: I need to complete TWO applications.
*I have one child, but there are two men who could possibly be the father: I need to
complete TWO applications.
* I am taking care of two grandchildren. Each has a different father and mother. I need to
complete TWO applications.
IF YOU HAVE QUESTIONS ABOUT HOW MANY APPLICATIONS TO COMPLETE, PLEASE CALL.
Complete
Doesn't Apply
I have attached copies of all of the support orders for these children.
Include divorce decrees, paternity orders, temporary orders, Juvenile Court orders, etc.
Complete
Doesn't Apply
I have attached a copy of each child's birth certificate who was not born in Utah.
If the child(ren) was born in Utah, you do not need to provide us with a birth certificate.
Complete
Doesn't Apply
I have attached copies of the paternity establishment documents if paternity has been
legally established for any child on this application.
If paternity was established by signing a UTAH Voluntary Declaration of Paternity, you do not need to
provide a copy to ORS/CSS. We will obtain that for you.
Complete
Doesn't Apply
I have attached a copy of the death certificate or obituary if either parent is deceased.
Complete
Doesn't Apply
I have completed and signed the "Statement of Arrears" if I have applied for or am
receiving cash assistance, or if I want ORS/CSS to collect past-due support for me.
Complete
I have read and marked ALL boxes in "Section X: Statements of Understanding"
Complete
I have marked ONLY ONE box in "Section XI: Request for Services"
Complete
I have signed and dated "Section XI: Request for Services"
Complete
I have made COPIES of all of the supporting documents to send to ORS. I am keeping all
ORIGINAL documents for my own records.
When your application(s) is complete, mail the application(s) and COPIES of all of the
supporting documents to:
Office of Recovery Services
Child Support Services
PO Box 45033
Salt Lake City, UT 84145-0033
Please be sure that your application is complete and signed.
Incomplete applications can delay approval of your cash assistance or medical assistance.
ORS/CSS will notify you if your application is not complete; however, we cannot return any of the documents to
you. You will have to complete the forms and gather your documents again.
Once your case is open, you may be asked for more information which will allow ORS/CSS to take the next step
on your case.
PAGE
9
NOTICE OF SERVICES
Utah Department of Human Services
Office of Recovery Services/Child Support Services
DETACH THIS FORM AND KEEP IT FOR YOUR RECORDS
The Office of Recovery Services/Child Support Services (ORS/CSS) provides child support services under the Federal/State IV-D
Child Support Program. These services are provided to people who: 1) receive cash assistance or Medicaid from the Department of
Workforce Services (DWS) or the Department of Health (DOH); 2) are no longer receiving cash assistance or Medicaid but continue
to receive child support services; 3) apply directly to ORS/CSS for IV-D child support services; and 4) are referred to ORS/CSS
while children are in state custody.
Services Provided
Case Opening and Locating the Non-Custodial Parent
We will open a case and try to locate the non-custodial parent’s address, income and assets through automated computer
matches to obtain or enforce a child support order.
Establish an Order for Paternity, Child Support and Medical Support
We will try to establish the paternity of children who are born to unmarried parents. We will provide genetic testing to identify
the paternity of a child. If there is no order we will try to establish a child support and/or medical support order. The order will
address each parent’s share of the total monthly obligation when the child(ren) is not living with that parent. We will enforce
the obligation of the non-custodial parent(s). The order will also require either parent to maintain medical insurance coverage
for the children, if it is available, and will require each parent to share equally in the children’s future uninsured medical
expenses. The parent(s) who has insurance coverage available will be required to get the insurance.
Enforcing a Utah Child Support Guidelines Order
We will enforce the support obligation of the parent(s) that does not have physical custody of the child. If the child is living
with a relative, we must open separate cases for the parents. If the child is in state custody, we must open cases against the
parents or other individuals as directed by Juvenile Court. When physical custody of the child changes, we may enforce the
obligation against the other parent(s) without modifying the order unless there is more than one child and physical custody of
the children is split between the parents. You will be notified if you are obligated to pay child support to our office.
Enforcing All Child Support Orders
While the case is open, we will try to collect support by taking the payments out of the non-custodial parent’s paycheck
(referred to as “income withholding”), levying bank accounts, taking federal and state offset payments, imposing liens for pastdue support on real and personal property and reporting these liens to the court in the name of ORS/CSS, reporting the past-due
amount to the credit bureau, and taking other enforcement actions we decide are appropriate.
When payments are received (except federal offset payments), they are generally credited in the following order: 1) to current
support debts; 2) to past-due amounts owed to the family, when the family is not receiving cash assistance; and 3) to past-due
support owed to the state, when the family is receiving cash assistance. We may split the support payments received among the
non-custodial parent’s current child support debts if s/he does not pay enough to cover the monthly amount due. If the noncustodial parent owes past-due support to more than one family, we may split the payment of the past-due amount among the
cases. Payments received from federal offset are credited as follows: 1) past-due amounts owed to the State; 2) past-due
amounts owed to the family. Payments are usually credited to support owed for the month in which they are received in the
ORS/CSS office. However, payments received during the last two working days of the month may not be credited to the case(s)
until the following month. We generally send support payments to the custodial parent within two days of receiving the
payment and federal offset payments within 6 months of receiving the money when the family is not receiving cash assistance
or the child(ren) is not in state custody.
ORS/CSS tries to credit payments properly. However, if the employer or non-custodial parent does not provide complete
information with the payment, the payment may be credited incorrectly. If we send you a payment that was intended for another
ORS/CSS debt, we may retain your future payment(s) to repay the debt. Sometimes a federal or state offset payment that has
been sent to the custodial parent is taken back by the source that sent it to us. If this happens, the custodial parent must repay
the take-back amount. Federal offset payments may be taken back up to six years.
DHS ORS ANIA 1/18/10
Page 10
Medical Support Enforcement
We automatically provide medical support enforcement services on all cases. If medical insurance coverage is not ordered in
the support order, ORS/CSS may modify the order to include a provision for medical insurance. When a parent is ordered to
maintain insurance coverage for the children, but fails to do so, we will send notice to the parent’s employer to enroll the
children in a health insurance plan. Utah’s child support guidelines allow the parent that is ordered to maintain insurance
coverage to receive credit for up to 50% of the child’s portion of the premium. The parent must request and provide to
ORS/CSS the insurance information in order to receive the credit. No retroactive credit will be given. The insurance credit will
be given by adjusting the base child support award amount in our case accounting record. The adjustment in the case
accounting record may make the child support amount go up or down depending on which parent is maintaining the insurance.
Interstate
If the non-custodial parent lives in another state, and we are unable to work the case ourselves, we must refer the case to the
other state. If the non-custodial parent does not live in the United States, the case can only be worked if we have an agreement
with the foreign country to work child support cases. If the foreign country requires your support order to be translated into
another language, you will need to have the order translated at your own expense. We cannot tell the other state or country how
to work your case.
Review and Adjustment of Support Orders
Either parent may ask us to review the support order once every three years from the time the order was issued or last modified,
or when a substantial change in circumstances has occurred. You must make a request for a review in writing. Not all
reviews will result in a change (adjustment) to the order. If there is a change, the amount could go up OR down. To get an idea
what the new amount may be, request a “Review and Adjustment Packet” by calling our Customer Service Unit, or you may
obtain this information from our web site.
Other Information about Services Provided
We ONLY collect spousal support (alimony) if the non-custodial parent is also ordered to pay current child support for
children living with the custodial parent.
We ONLY collect interest if it is listed as a specific dollar amount in a judgment, or in an interstate case if the other state
provides ORS/CSS with the specific interest amount, or if a case has been referred for criminal non-support prosecution.
We ONLY collect ongoing cash medical support if it is included as a specific dollar amount in your support order. We will
try to enforce judgments you obtain from the judicial district court for unpaid medical bills.
We ONLY collect ongoing child care expenses if a parent makes the request, the specific dollar amount for child care is
included in an order along with a child support obligation, and neither parent is disputing the monthly child care amount. We
will try to enforce past-due child care expenses if you obtain a judgment from the judicial district court.
We DO NOT represent either parent. We are assisted by attorneys from the Utah Attorney General’s Office. They represent
the State and are not personal attorneys for either parent. This means that no attorney client relationship exists between you and
the State’s attorney. If you want legal advice, you will need to consult with a private attorney.
We decide the actions that we will take on your case. This includes possible civil or criminal actions. You may want to
consider using a private attorney or agency if you want legal action or a service that we do not provide, or if you want to be
involved in deciding exactly how your case is worked.
We cannot address custody, visitation, property settlement issues or any other non-support issues. We cannot provide all
the services you may receive from a private attorney. Services are limited to those described in this Notice.
We will attempt to collect child support until the child is legally emancipated. For Utah child support orders, the age of
emancipation is when the child turns 18 or graduates with his/her normal graduating high school class, whichever occurs later.
We will presume a child turning 18 prior to graduation will be graduating with his/her class unless a parent provides
documentation stating otherwise. A child may also emancipate in Utah by marrying or joining the armed forces. If your order
was issued by a state other than Utah, the child will emancipate based on the laws of that state.
We cannot always collect past-due support. Based on Utah law, we can only collect past-due support for 4 years after the
last child in a Utah order reaches the age of majority (18), or for eight years after the arrears have been reduced to a sum-certain
judgment by a Utah district court, whichever period is longer. If your order was issued by a state other than Utah, we may be
able to apply that state’s statute of limitations and extend the collection time period.
DHS ORS ANIA 1/18/10
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Important Information to Parents Receiving Cash Assistance and/or
Medicaid
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You cannot enter into an agreement with the non-custodial parent to accept “in-kind” support in place of the court-ordered
support. If you do accept “in–kind” support, you will need to pay ORS/CSS an equal cash amount. Examples of in-kind
support are food, clothing, housing, utilities, etc.
When your cash assistance and/or Medicaid case closes, we will continue to provide full services (such as child support,
spousal support and medical support enforcement), unless you request to close your case. If you were only receiving
Medicaid and opted not to receive child support services, we will continue to provide only medical support enforcement.
You assigned (transferred) your past, present and future child, spousal and medical support rights to the State when you
became eligible for cash assistance. You will NOT receive your monthly child support payments while you receive cash
assistance. We will keep any support the non-custodial parent pays up to the total amount of cash assistance you receive.
If the amount of the support collected exceeds the total cash assistance you receive, the excess amount will be sent to you.
If legal paternity for your child(ren) has not been established, you must cooperate in identifying and locating all possible
alleged fathers and in establishing paternity for your child(ren) unless ORS/CSS determines you are unable to meet the
cooperation requirements, or the Department of Workforce Services (DWS) determines there is good cause or other
exception to cooperation.
FEES FOR SERVICES
Charged to individuals who are NOT receiving cash assistance or Medicaid.
PAYMENT PROCESSING: We charge a $5.00 administrative fee to the applicant each time a payment is processed and
sent by mail, Direct Deposit or EPPICard. The fee will not exceed $10.00 per month. This charge will be withheld from the
support payment before it is sent.
PAYMENT CONVENIENCE FEE: We charge a $1.00 convenience fee to the payor for each payment transaction
processed online using the Online Payment Web Application. A $5.00 convenience fee is charged to the payor for each
payment transaction processed over the phone. The fees are paid by the payor in addition to the payment amount being made.
EPPICard FEES: There are no fees for withdrawing money from a teller at a bank that displays the MasterCard brand
mark, or to make purchases from a merchant that accepts MasterCard. There is a transaction fee of $0.85 each time you use
an ATM to withdraw money and a $0.50 fee for a balance inquiry.
ANNUAL FEE FOR CHILD SUPPORT SERVICES: Effective on July 1, 2007, we charge an annual fee of $25.00 in
each case to the custodial parent who has never received cash assistance. The fee is retained from child support collected on
behalf of the custodial parent after $500.00 has been collected within the one-year period. The one-year period is measured
from October 1 through September 30 each year, beginning October 1, 2006.
FEDERAL OFFSET PAYMENT CHARGE: We charge the case applicant up to $25.00 if we take the non-custodial
parent’s federal offset payment. If the custodial parent is the applicant, we will withhold the charge from the federal offset
payment before it is sent. If the non-custodial parent is the applicant, a $25.00 charge will be added to the non-custodial
parent’s obligation.
PATERNITY ESTABLISHMENT SERVICES: If the mother does not name all possible consorts at the time a case is
opened, we will charge her for the cost of additional genetic testing as additional possible consorts are named.
INTERSTATE CASES: There may be other charges if your case is referred to another state and that state charges a fee.
If your court order exempts you from paying fees, you may ask the Clerk of Court who issued your order to initiate a Notice to
Withhold Income for Child Support to have the payments sent to our office and forwarded to you. No additional services are
provided on these cases and no fees are charged. See our web site for more information or contact the Clerk of Court.
ORS/CSS RESERVES THE RIGHT TO GIVE FURTHER NOTICE ABOUT ADDITONAL COSTS AND FEES
THAT MAY BE CHARGED IN THE FUTURE
DHS ORS ANIA 1/18/10
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Release of Case Information
The names and social security numbers of the custodial parent, the non-custodial parent and the children are sent to the Federal
Case Registry, where the information may be accessed by authorized agencies, such as child support agencies in other states.
The address or employer’s address of the non-custodial parent or the custodial parent and children’s address may be released to
the other party or to the other party’s attorney if we receive a written request and a parent-time order. If we receive a request to
release your location information, you will be sent a notice that gives you the opportunity to contest the action and to provide us
with documentation that will safeguard your location information. The address or employer’s address of the non-custodial
parent or custodial parent may be released under the Government Records Access Management Act (GRAMA) to the other
party or his/her attorney if needed to serve legal process to establish or modify a child support, spousal support, medical
support, or child care order or judgment.
If a National Medical Support Notice is sent to the employer of either parent to enroll the children in an insurance plan, the
addresses of the custodial parent and the non-custodial parent will be included in the referral. If the case is sent to the Attorney
General’s Office for a court action, the addresses of the custodial parent and the non-custodial parent will be included in the
court documents, which become public records, unless we are provided with an alternate address. If the case is sent to the
Office of Administrative Hearings, the addresses of the custodial parent and the non-custodial parent will be included in the
hearing documents. If the case is referred to a child support agency in another state, the addresses of the custodial parent and
the non-custodial parent will be included in the referral. If you have a domestic violence issue and you would like ORS/CSS to
attempt to safeguard your case information and your children’s case information so that it will not be released, see the “Release
of Information” section on the attached application.
Based on section 466(a)(13) of the Social Security Act [42 U.S.C. 666(a)(13)] it is mandatory for a state’s child support
enforcement program to request an individual’s social security number in order to locate individuals for purposes of establishing
paternity and establishing, modifying and enforcing support obligations.
Help Us Help You
Cooperate with ORS/CSS: Provide truthful and correct information about the other parent and any past-due support that
may be owed; answer questions regarding your case; give us copies of orders and the child support worksheets; appear at
interviews and at administrative or court hearings; submit to genetic testing, etc.
Non-Cooperation: If you are receiving cash assistance or certain Medicaid benefits and do not cooperate with ORS/CSS,
your cash assistance may be reduced, you may be removed from the Medicaid card, and/or your DWS case closed unless
ORS/CSS determines that you have cooperated in good faith. If you feel cooperation may cause physical or emotional harm to
you or your children, contact your DWS worker. If you are NOT receiving cash assistance and do not cooperate and ORS/CSS
is unable to take the next step on your case, your case will be closed.
Tell ORS/CSS immediately of new information, such as:
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Your current name (for example, if you remarry), address, social security number, phone number and your employer’s
name and address.
The social security numbers of everyone involved in your case.
The non-custodial parent’s address, phone number, employer, or insurance changes.
If anyone enrolls the children in a health insurance plan, or if the children are dropped from the health insurance plan.
If your children are receiving cash assistance and tell us when they are no longer eligible to receive child support (for
example: a child who has emancipated or is no longer living with you). You will need to repay any support payments
sent to you for ineligible children.
Provide copies of all your support orders (for example: legal separation order, divorce decree, paternity order, Juvenile
Court order, modification order, or judgment for past-due child support, medical support, and/or child care.
Judgments must be issued by the judicial district court and not by a small claims court.
If you are working with a private attorney or agency to collect your child support. Also tell the private attorney or
agency that you have a case with ORS/CSS.
If an attorney or agency files any legal pleadings in court in regard to your child support.
Reductions of court-ordered support that could result in an overpayment to the custodial parent. If we are not informed
of changes to the support amount, we may offset future payments to adjust for the overpaid amount.
Any support payments you receive directly from the non-custodial parent or from any other source. Send the payments
to ORS/CSS at the payment address given below. Include a note that provides your case number or the non-custodial
parent’s social security number and a statement that indicates that the payment was made directly to you. Without a
note, the full payment may not be credited to your case.
DHS ORS ANIA 1/18/10
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To Contact ORS/CSS or To Receive More Information
Mail
Payments:
Office of Recovery Services
Child Support Services
PO Box 45011
Salt Lake City, UT 84145-0011
Correspondence:
Office of Recovery Services
Child Support Services
PO Box 45033
Salt Lake City, UT 84145-0033
Internet
Office of Recovery Services Web Site: Go to www.ors.utah.gov to obtain additional information about the Office of
Recovery Services.
ORS Interactive Web Site: Use our interactive web site to access payment and case status information. You can also
submit new address, employment and insurance information, and submit questions about your case electronically. Go to
http://orsica.dhs.utah.gov where you will find a log-in page and instructions for setting up your account.
Telephone:
(801)536-8500
Automated Case and Customer Service System (ACCESS): ACCESS is the ORS voice-activated, self-service phone
system. The ACCESS phone number is (801)536-8500. Use ACCESS to make payments or to hear payment information. Use
ACCESS to ask questions about ORS procedures and services, to request forms, and to update your information (address,
employer, etc.). ACCESS provides the most information if you have your case number and PIN number ready. If you do not
have a PIN number, you will be given a chance to register for the ACCESS system during your call. If ACCESS cannot
provide the information you need, you will be given an opportunity to speak with one of our customer service representatives.
Reasonable accommodations per Americans with Disabilities Act available with minimum 3 days advance notice.
DHS ORS ANIA 1/18/10
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