Fill and Sign the Fi Hh Iwpk I Cilly Com11mniti Form

fi,_-,,hh, I'wpk I /c,ill/,y Com11mniti,~. fJitpl&"III Alelf'lilL' Hc-ilh.11-1 Ul s. ....... D D D D D D D D CHILD SUPPORT ENFORCEMENT DIVISION APPLICATION FOR NON -PUBLIC ASSISTANCE CHILD SUPPORT SERVICES Services Child support services are provided to either parent, or to a third -party with whom the child(ren) resides by court order • Enforcement actions, see Terms and Conditions or with the consent of the parent who has legal custody. We can help with: We cannot help with: • Parentage establishment • Establishment of a support and medical order • Enforcement of a support and medical order • Custodianship • Custody establishment or modification • Visitation establishment or modification Interstate Cases: The Child support Enforcement Division (CSED) may request assistance from a child support agency in another state to work your case. If it is referred to another state that state controls the action taken in the case. Cost of Services The CSED is required to charge an application fee to individuals applying for child support services. It is non -refundable , even if the CSED determines your case is unworkable. Please attach your payment to this application. It must be a cashier’s check or money order. The CSED cannot accept personal checks or cash . Application Fee $25.00 I am not receiving Medicaid No Fee I am receiving Medicaid I am the Custodial Parent Non -Custodial Parent Other Custodian (relationship) _______________________ I am applying to receive services from the Mother Father I understand the CSED will provide complete child support serveries. I request a modification of the support order. The information I am providing in this application is true to the best of my knowledge. Date________________________ Signature________________________________________ Release of Information Information (including Social Security Numbers, names, and addresses) provided in this application or through other means may become part of the public record and may be shared with others. Safety Information If you are concerned that the release of case information could result in physical or emotional harm to you or your family, or if you have a protective or restraining order against a receiver of the information, you must notify the CSED. IMPORTANT Before getting started decide how many applications you will need. Are you a Custodial Parent/Other Custodial Party ? A separate application is needed for each alleged father. A separate application is needed for each parent from whom you are seeking support. Are you a Non -Custodial Parent? A separate application is needed for each Custodial Parent you will send child support to. Incomplete responses may delay service. Please respond to questions as completely as possible. DD D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D Marital Status of Parents and Child Support Order Information Marital Information Marriage date:___________________________ No , parents were not married Where were parents married? ( city/c nty/st ) _______________________________________________________ ____________ Divorce Information Date on divorce order:_____________________ divorced Cause Number:_____________________________ city/c nty /st:____________ ________________________ ________ Child Support Order Is the child support order different from the divorce order? Not Yes No If yes, please provide Cause Number: _________________ _ city/cnty/st : ______________________________________ If no support order exists has legal action been started? Yes No Certified copies of all orders must be included with submission of this application. Photocopies are not accept able . A certified copy bears an original stamp from the clerk of court, in which the order(s) was filed. Custodial Parent/ Other C ustodian Information Last Name First Name Mid Name/Int./Maiden Name _____________________________________ ____________________________ __________________________ Alias/Other names used Race Social Security Number Gender F M __________________________________ _______________ ______ ___________________ Date of birth_____________ Place of birth (city/st) ________________________________________________________ If Native American Tribal Name__________________________________________ Enrollment#________________ Lives on a reservation? Yes Reservation Name_____________________________________________ No Mailing Address ( Current Last Known) __________________________________________________________ Street Address ( Current Last Known) __________________________________________________________ How long has the Custodial Parent/ Custodian lived in the above named state ? _ ____ _______________________________ Primary Phone # _____________________________ ______ Email Address______________________ _____ __________ Other Phone#_____________________________ cell message other (explain)_ ______________________ Have you ever received: If Yes, where? (city/st ) and when? Child Support Services in another state? Yes _________________________________________ No Public Assistance in Montana or in another state? Yes _________________________________________ No Medicaid in Montana or in another state? Yes _________________________________________ No Parents ( children’s grandparents) If deceased, enter name and indicate deceased o the address line. Name of Custodial Parent’s Father_____________________________________________ Phone#__________________ Address_____________________________________________________________________________________________ Name of Custodial Parent’s Mother ____________________________________________ Phone#__________________ Address_____________________________________________________________________________________________ Custodial Parent Information : Complete only if you are a Parent — Other custodian need not complete Employer Information Employer__________________________________ Address_______________________________________________ Phone#________________ Hours/w eek________ Current Wage $______ Usual Occupation__________________ Union membership Yes No Unknown If yes, Union Name & phone#______________________________ Does the union provide health insurance ? Yes No Unknown Military Service Member or former member of the Armed Forces Yes No Receiving military retirement? Yes Amount/month $___________________________________ No Receiving military disability income? Yes Amount/month $___________________________________ No 2 DD D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D Non -Custodial Parent Information Last Name First Name Mid Name/Int./Maiden Name _________ Gender ____ F _____ M ___________________ ____________ Alias/Other names used __________________________________ ________________ Race _______________ __________________________ Social Security Number _________________________ Date of birth_____________ Place of birth (city/st) ________________________________________________________ If Native American Tribal Name__________________________________________ Enrollment#________________ Lives on a reservation? Yes Reservation Name_____________________________________________ No Mailing Address ( Current Last Known) __________________________________________________________ Street Address ( Current Last Known) __________________________________________________________ How long has the Non -Custodial Parent lived in the above named state?_____________________________________ ____ Primary Phone #_____________________________ ______ Email Address________________________________ _____ Other Phone#_____________________________ cell message other (explain)_ ______________________ Have you ever received: If Yes, where? (city/st ) and when? Child Support Services in another state? Yes _________________________________________ No Public Assistance in Montana or in another state? Yes _________________________________________ No Medicaid in Montana or in another state? Yes _________________________________________ No Parents ( children’s grandparents) If deceased, enter name and indicate deceased o the address line. Name of Custodial Parent’s Father_____________________________________________ Phone#__________________ Address_____________________________________________________________________________________________ Name of Custodial Parent’s Mother ____________________________________________ Phone#__________________ Address_____________________________________________________________________________________________ Non -Custodial Parent Information Employer Information Employer__________________________________ Address_______________________________________________ Phone#________________ Hours/w eek________ Current Wage $______ Usual Occupation__________________ Union membership Yes No Unknown If yes, Union Name & phone#______________________________ Does the union provide health insurance? Yes No Unknown Military Service Member or former member of the Armed Forces Yes No Receiving military retirement? Yes Amount/month $___________________________________ No Receiving military disability income? Yes Amount/month $___________________________________ No Child Information — Child(ren) for whom you are applying for services Child resides with _________________________________ _____________________________________ ____ If there are more than three children include a ll requested information on a separate sheet. CH#1 -Full Name Date of Birth Place of Birth (city/st ) Sex M F Social Security # Race ____________________________ ____________ ____________________ _________________ _____________ Were parents married at time of birth? Yes No Were parents living together? Yes No Wh ere conceived (city/st )__________________________________________________ Has p arentage been established? No, it has not Yes, genetic testing Yes, acknowledgment of parentage Yes, court order If yes, provide a copy of the genetic results/acknowledgement/court order that establishes parentage. Provide where is it filed city/cnyt/st : ___________________________________ __________________________________ Social Security Benefits Is child receiving Social Security? Yes Type & Amount $____________________ No 3 D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D ____________________________ Child Information — Child resides with _______________________ ___________________________________ CH#2 -Full Name Date of Birth Place of Birth (city/st ) Sex M F Social Security# Race: ____________________________ ____________ ____________________ _____________ _________________ Were parents married at time of birth? Yes No Were parents living together? Yes No Wh ere conceived ( city/s t) __________________________________________________ Has p arentage been established? No, it has not Yes, genetic testing Yes, acknowledgment of parentage Yes, court order If yes, provide a copy of the genetic results/acknowledgement/court order that establishes parentage. Provide where is it filed city/cnyt/st : ___________________________________ __________________________________ Social Security Benefits Is child receiving Social Security? Yes Type & Amount $____________________ No Child Information — Child resides with_______________ ___________________________________ _____ ___ CH#3 -Full Name Date of Birth Place of Birth (city/ st) Sex M F Social Security# Race: ____________________________ ____________ ____________________ _____________ _________________ Were parents married at time of birth? Yes No Were parents living together? Yes No Wh ere conceived (city/s t) __________________________________________________ Has p arentage been established? No, it has not Yes, genetic testing Yes, acknowledgment of parentage Yes, court order If yes, provide a copy of the genetic results/acknowledgement/court order that establishes parentage. Provide where is it filed city/cnyt/st : ___________________________________ __________________________________ Social Security Benefits Is child receiving Social Security? Yes Type & Amount $____________________ No Health Insurance Information for Custodial & Non -Custodial Parent s Health Insurance Is available through employment, union or other group to: Custodial Parent Non -Custodial Parent Both Parents Neither Parent Custodial Parent Insurance Company____________________________________ Phone#_________________ Address_________________________________________________ Policy#______________ Group#___________ All persons insured under policy________________________________________________________________________ Non -Custodial Parent Insurance Company____________________________________ Phone#_________________ Address_________________________________________________ Policy#_____________ Group#___________ All persons insured under policy________________________________________________________________________ Health Insurance Information for child(ren) named in this application Health Insurance Yes Who provides? Custodial Parent Non -Custodia l Parent No child is not covered Other (name/relationship) _________________ ________________ _ Insurance Company____________________________________ _ Phone #_____________ ______________________ Address______________________________________________ _ Policy#____________ Group#_____________ _ If child(ren) is covered under more than one policy provide: Policy#_________________ Group #_____________ _ Insurance Company _______________________________________________________________________________ _ If the health insurance information for one the children differs from above please complete: CHILD -Full Name Yes Who provides? Custodial Parent Non-Custodial Parent No child is not covered Other (name/relationship) _______________ _____ Insurance Company_____________________________________ Phone#___________________________________ If more than on child has health insurance that differs from what has been provided include it on a separate sheet 4 D D D D D D MONTANA Hca/1/11 /\:er/,· , I lcaltliy Co,mmmitic,.. Dilfll h nttlhl,J htl&H ILi s.,., CHILD SUPPORT ENFORCEMENT DIVISION APPLICATION FOR NON -PUBLIC ASSISTANCE Child Support Received or Paid Support Received The CSED will collect ordered maintenance or alimony if it is also child collecting support. Initial all boxes you check and list payments on the payment tables. I, the undersigned say, I received payments directly from the Non -Custodial Parent. I received payments from another state agency or court. Please provide a certified copy of pay records from the agency or court. State agency or court (name/address/phone#)________________ ________________________________________ I have never received a child support payment. Support Paid Initial all boxes that you check. List payments on the attached payment tables. Provide a certified copy of pay records from the agency or court. I, the undersigned say, I made payments directly to N ame of the individual, not an agency or court ________________________________________________________ I made payments to another state agency or court. Please provide a certified copy of pay r ecords from the agency or court. State agency or court (name/address/phone#)________________________________________________________ I have never made a child support payment. If you have received or paid child support for the c hildren in this application Complete the tables on page 6 5 Payment Tables Year: _______ Year: _________ Year: _________ Month Amount Due Amount Paid If Paid to or Rec