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LDSS-4882 ( 7/12) _ _____________________________________________ Information about Child Support Services and Application/Referral for Child Support Services _ _____________________________________________ New York State Office of Temporary and Disability Assistance Center for Child Well -Being Division of Child Support Enforcement Need additional information on child support? Visit our website at childsupport.ny.gov W 1 childsupport.ny.gov GENERAL INFORMATION If you need language assistance, please advise the Child Support Enforcement Unit so that translation and/or interpretation services can be provided. Read the Information about Child Support Services (pages 2 – 7) carefully before completing th e detachable Application/Referral for Child Support Services form (pages A -1 – A -8) . It contains important facts and information you will need to know and understand regarding child support enforcement services. TABLE OF CONTENTS INFORMATION ABOUT CH ILD SUPPORT SERVICES ...................................................... 2 SECTION 1 – ELIGIBILITY, ASSIGNMENT, AND AVAILABLE SERVICES .......................................... 2 ELIGIBILITY FOR CHILD SUPPORT SERVICES ............................................................................................ 2 ASSIGNMENT AND COOPERATION WITH CHILD SUPPORT ...................................................................... 2 CHILD SUPPORT SERVICES PROVIDED ....................................................................................................... 2 INFORMATION ABOUT BASIC CHILD SUPPORT OBLIGATIONS ............................................................... 3 UNDERSTANDING THE CHILD SUPPORT SERVICES PROVIDED ............................................................. 4 SECTION 2 – RIGHTS AND CONSEQUENCES RESULTING FROM PATERNITY ESTABLISHMENT AND RIGHT TO NOTICE OF LEGAL PROCEEDINGS .................... 5 RIGHTS AND CONSEQUENCES OF ESTABLISHING PATERNITY ............................................................... 5 RIGHTS TO INFORMATION REGARDING LEGAL PROCEEDINGS ............................................................. 5 SECTION 3 – CHILD SUPPORT POLICIES ................................................................................................... 5 SAFETY CONCERNS .......................................................................................................................................... 5 SAFEGUARDING AND CONFIDENTIALITY OF PERSONAL INFORMATION ............................................. 6 DISTRIBUTION POLICY .................................................................................................................................... 6 SECTION 4 – LEGAL SERVICES AND COST RECOVERY ........................................................................ 6 LEGAL SERVICES .............................................................................................................................................. 6 COST RECOVERY FOR LEGAL SERVICES ..................................................................................................... 7 SECTION 5 – ANNUAL SERVICE FEE ............................................................................................................ 7 SECTION 6 – PAYMENT AND CONTACT INFORMATION ....................................................................... 7 PAYMENT OPTIONS .......................................................................................................................................... 7 CUSTOMER SERVICE/ACCOUNT INFORMATION ........................................................................................ 7 APPLICATION/REFERRAL FOR CHILD SUPPORT SE RVICES .................................. A-1 SECTION A – APPLICANT /R ECIPIENT INFORMATION ...................................................................................... A-1 Part I – Custodial Parent (CP) or Guardian Information .............................................................................. A-1 Part II – Noncustodial Parent (NCP)/Putative Father (PF) Information ....................................................... A -3 Part III – Child Information ............................................................................................................................ A -5 Part IV – Foster Care Information (Agency Use Only) .................................................................................. A -6 SECTION B – SUPPORTING DOCUMENTATION ................................................................................................ .. A -7 SECTION C – APPLICATION /A FFIRMATION FOR CHILD SUPPORT SERVICES ................................................. A -8 W 2 childsupport.ny.gov INFORMATION ABOUT CHILD SUPPORT SERVICES This document provides individuals interested in child support services with important information about the program (Sections 1 -6) and includes a detachable application/referral for child support services. Section 1 identifies who is eligible to receive child support services, explains the assignment of support rights and cooperation, a nd provides a summary of child support services and the basic child support obligation. Section 2 discusses rights and responsibilities resulting from paternity establishment and right to notice of legal proceedings . Section 3 provides the State's child support policies . Section 4 discusses legal services and cost recovery . Section 5 discusses the annual service fee and Section 6 provides payment and contact information. This information must be provided to all applicants for child support services and to applicants and recipients of Temporary Assistance for Needy Families (TANF), Medicaid and Title IV -E Foster Care who are referred to the Child Support Enforcement Unit. If the child is in foster care, the applicant or recipient is the Commissioner or D esignee of the soc ial services district or the Commissioner or Designee of the Office of Children and Family Services. SECTION 1 – ELIGIBILITY, ASSIGNMENT, AND AVAILABLE SERVICES Any parent or nonparent caregiver acting as guardian of at least one child under the age of 21 is eligible to apply for child support services. Such person is considered the custodial parent in the child support case. If you are applying for, or receiving, Temporary Assistance (officially termed “Family Assista nce” or “Safety Net Assistance”) for the child, child support services may be provided to you based on your application for this program. Child support services may also be provided if you are applying for Medicaid for yourself and the child and you comple te an application/referral for child support services. Child support services will continue after you stop receiving Temporary Assistance or Medicaid unless you request your child support case be closed. Child support services are also provided for a child placed in foster care and may continue after the foster care placement ends. If the child returns to you after being discharged from foster care, child support services will continue unless you request otherwise. A child under the age of 21 or a noncustodial parent or putative (alleged) father may also apply or be eligible for child support services. ELIGIBILITY FOR CHILD SUPPORT SERVICES If you are an applicant/recipient of Temporary Assistance for the child, or Medicaid for yourself and the child, or your child is in Title IV -E Foster Care, you are required to assign to the social services district rights you have to support on your own behalf and any rights to support on behalf of any family member for whom you are applying for, or receiving assistance. For Medicaid applicants/recipients, this assignment is limited to medical support only. When applying for, or receiving Temporary Assistance, your assignment of support rights is limited to support that accrues during the peri od that you or the family member receives assistance. You are required to assign these support rights and, unless you claim good cause or domestic violence for not doing so, cooperate with the Child Support Enforcement Unit to: ASSIGNMENT AND COOPERATION WITH CHILD SUPPORT • Locate noncustodial parents and putative fathers, including biological parents or stepparents; • Establish paternity for each child born out -of -wedlock for whom you are applying for, or receiving Temporary Assistance, Medicaid, or Title IV -E Foster Care; • Establish, modify, or adjust or ders of support; and • Collect and enforce orders of support through the Support Collection Unit. If you are receiving Temporary Assistance for the child or Medicaid for yourself and the child, you will be sanctioned for failing to cooperate absent a determination of good cause or domestic violence , if applicable. The following services are provided by the Child Support Enforcement Unit as appropriate, with your cooperation: CHILD SUPPORT SERVICES PROVIDED • Establishment of a case record. • Location of the noncustodial parent or putative father, including obtaining information about addresses, employment, other sources of income and assets, and health care coverage. L D S S - 4 8 8 2 W 3 childsupport.ny.gov • Assistance to establish paternity (legal fatherhood) for a child born to unmarried parents by voluntary acknowledgment of paternity or by filing a petition with the court. • Assistance with filing court petitions to establish and modify an order of support according to the New York State child support guidelines, including obtaining health insurance benefits, if available, from either parent. • Assistance in making an order of support payable to the Support Collection Unit. • Collection and distribution of support payments. This may include collection and distribution of child support; child and spousal support; educational expenses; child care expenses; and cash medical support, if any of these are included in the order of support made payable through the Support Collection Unit. • Enforcement of support obligations using all available administrative remedies including, but not limited to: income withholding from employment, benefits, or other income; interception of federal and New York State tax refunds; seizure of assets; credit reporting of support debt; suspension of the noncustodial parent’s New York State driving privileges; and referral to the New York State Department of Taxation and Finance for collection. Court ordered health insurance benefits are also enforced by the Child Support Enforcement Unit. • Filing and prosecuting violation petitions to enforce an order of support through court when administrative remedies are unsuccessful. • Legal services (optional to the applicant) upon signing a Right to Recovery Agreement for Legal Services (LDSS - 4920) for court proceedings. Costs will be recovered for legal services. • Child support services listed above where parents live in other counties, states, or countries. • Continuation of child support services listed above when a family is no longer eligible for Temporary Assistance, Medicaid, or foster care. • New York State Child Support Website: childsupport.ny.gov • New York State Child Support Customer Service Helpline at 888- 208-4485. The Child Support Enforcement Unit can help you establish or modify a child support order based on New York State’s child support guidelines. The basic child support obligation (BCSO) includes a percentage -based obligation, a provision for health insurance coverage and/or cash medical support, child care expenses, and educational expenses for the child, if determined by the court (refer to Family Court Act Section 413). INFORMATION ABOUT BASIC CHILD SUPPORT OBLIGATIONS Percentage-Based Obligation : The base calculation paid by the noncustodial parent is determined using a fixed percentage of combined parental income, based on the number of children involved. 1 child……………….17% Example: 2 children……………25% The noncustodial parent’s pro rata share of income available 3 children……………29% for support is $25,000. For one child, application of the guidelines 4 children……………31% percentage yields an annual percentage -based obligation of $4,250 5 or more……at least 35% (i.e., 17% of $25,000). The percentage guideline is applied to combined parental income up to $136,000 (minus Medicare, Social Security , New York City or Yonkers tax , certain unreimbursed employee business expenses , certain alimony or maintenance paid or to be paid, and certain child support actually paid ). “Income” means such income as reported on the federal income tax r eturn and, to the extent not reported on the tax return, workers’ compensation benefits, disability payments, unemployment benefits, social security benefits, veteran’s benefits, pensions and other forms of income. A bove $136,000 (which will increase in 2014 and every two years thereafter with changes in the Consume r Price Index for All Urban Consumers ) the court determines whether or not to use the percentage guidelines . The court may deviate from the percentage -based obligation based on the factors set fo rth in Family Court Act Section 413(1)(f). Low Income Obligation : When the noncustodial parent’s income is determined by the court to be at or below the federal poverty level for a single person, the presumptive support amount is $25 per month. When income is at or below the self -support reserve (135% of the federal poverty level), but above the federal poverty level, the presumptive support amount is $50 per month. Additional Elements of Support : The court must determine the parties’ obligation to p rovide health insurance benefits, pay cash medical support toward the cost of health insurance or public coverage, and pay for other health W 4 childsupport.ny.gov care expenses not covered by insurance. Health care coverage may be provided through a public entity or by a parent through an employer or organization, or through other available health insurance or health care coverage plans. The BCSO must also be increased to cover reasonable child care expenses if the custodial parent is working , in school , or in a vocational traini ng program. If the custodial parent is looking for work and incurs child care expenses, the court may determine the noncustodial parent’s share of these expenses. In addition, the court may increase the BCSO to cover the reasonable educational expenses of the child. Foster Care and Child Support Obligations : In foster care cases, both parents are noncustodial parents with an obligation to pay support based on the child support guidelines. However, where the amount of support determined under the guidelines exceeds the costs of foster care, the Child Support Enforcement Unit may argue to the court that the amount of support is unjust or inappropriate and that the amount of support ordered to be paid should not exceed the actual costs of foster care plus any costs attributable to the costs of medical assistance paid on behalf of the child. Modification of Orders : • Original order of support was entered prior to October 13, 2010; or The Child Support Enforcement Unit can assist you in filing a petition to modify your order of support, if needed. Either party has the right to seek a modification of the order of support based upon a showing of a substantial change in circumstances. If the order was effective on or after October 13, 2010, i ncarceration shall not be a bar to finding a substantial change in circumstances provided such incarceration is not the result of non- payment of a child support order, or an offense against the custodial parent or child who is the subject of the order or judgment. Additionally, under certain conditions pursuant to Family Court Act Section 451(2)(b) , an order of support can be modified based upon: (1) the passage of three years since the order was entered, last modified or adjusted; or (2) a change in either party’s gross income by fifteen percent or more since the order was entered, last modified or adjusted. Bases (1) and (2) for seeking a modification of the order of support do not apply if the: • Parties entered into a validly executed agreement or stipulation prior to October 13, 2010 which was incorporated into the original order of support; or • Parties have specifically opted out of the bases provided in (1) and/or (2) in a validly executed agreement or stipulation entered into on or after October 13, 2010. Cost of Living Adjust ment: Every two years the Child Support Enforcement Unit will review the account to determine whether the account is eligible for a cost of living adjustment (COLA). An order of support is eligible for a COLA if: (1) it has been at least two years since th e order was issued or modified by the court, or last received a COLA; and (2) the sum of the annual average changes in the Consumer Price Index for All Urban Consumers is 10% or greater since the entry of the last order. The COLA adjustments are made without going to court. In non- Temporary Assistance cases, a notice is sent to both parties when an account is eligible for a COLA, and either parent may request the adjustment. For cases where the custodial parent or child is on Temporary Assistance , the COLA is automatically made when the account becomes eligible — without either parent requesting the adjustment. The Child Support Enforcement Unit will provide all child support services considered pr oper for your case as defined under federal and New York State law and rules. With your assistance and cooperation, services may be provided to you for as long as child support payments are due and owing. However, if the recipient of services is not receiv ing Temporary Assistance or Medicaid, the child support case may be closed for a number of reasons including: UNDERSTANDING THE CHILD SUPPORT SERVICES PROVIDED • Paternity cannot be established; • The noncustodial parent/putative father cannot be located after diligent effort or is incarcerated with no chance of parole, institutionalized, or permanently disabled with no ability to pay support ; • The recipient of services fails to cooperate or provide information that is essential to the next step in providing services; • The recipient of services ma kes a written request to close the case; or • The Child Support Enforcement Unit is unable to contact the recipient of services by telephone or mail. In order for the Child Support Enforcement Unit to continue to provide you with effective service, you must contact the Child Support Enforcement Unit to report any change in your address or telephone number, or to report any new information on the other parent of the child for whom you are seeking child support. W 5 childsupport.ny.gov SECTION 2 – RIGHTS AND CONSEQUENCES RESULTING F ROM PATERNITY ESTABLISHMENT AND RIGHT TO NOTICE OF LEGAL PROCEEDINGS Paternity is established when parents sign a voluntary Acknowledgment of Paternity or when the court determines the father of the child and issues an “order of filiation.” RIGHTS AND CONSEQUENCES OF ESTABLISHING PATERNITY • Under New York State law, t he noncustodial parent will be chargeable by the court to pay support until the child is 21 years of age. • The child gains rights to inheritance from his or her parents. Parents also may have ri ghts of inheritance from their child. • The child may be entitled to receive death or disability benefits if either parent dies or becomes permanently disabled. • The noncustodial parent has the right to ask the court for visitation with and/or custody of the child. • The noncustodial parent will also generally have the right to notice to adoption and foster care proceedings. You have the right to be kept informed of the time, date, and place of any court proceedings involving you. You will be provided with a copy of any order establishing, modifying, adjusting, or enforcing an order of support, or any order dismissing the peti tion. RIGHTS TO INFORMATION REGARDING LEGAL PROCEEDINGS SECTION 3 – CHILD SUPPORT POLICIES If you have concerns that seeking to establish or enforce an order of support will create a risk of harm to yourself or the child, contact the Child Support Enforcement Unit to discuss these concerns . The Child Support Enforcement Unit can assist you in preventing your address or other personal identifying information from appearing on court documents or other documents pertaining to your child support case. SAFETY CONCERNS The Child Support Enforcement Unit shall prohibit disclosure of location information if requested by any person, where that person provides evidence that: • The person resides in a domestic violence shelter; • An order of protection has been entered; • A court has determined that contact with the noncust odial parent creates a risk of physical or emotional harm to a child or custodial parent; • A good cause determination has been made by the Temporary Assistance or Medicaid worker; or • A domestic violence liaison has determined that there is reason to believe that disclosure of location information may result in physical or emotional harm to the custodial parent or child. If your case is to be referred to the Child Support Enforcement Unit as a requirement for receipt of Temporary Assistance for the child and you fear that you or the child will be at risk of family or domestic violence if paternity or an order of support is established or enforced, you will be referred first to a domestic violence liaison by the Temporary Assistance worker. The domestic violence liaison may grant you a full or partial waiver from the requirement to cooperate with the Child Support Enforcement Unit. If you are applying for Medicaid for yourself and the child, you may claim good cause from c ooperating with the Child Support Enforcement Unit to the Medicaid worker if: • Cooperation is expected to result in physical or emotional harm of a serious nature to the child for whom support is sought; • Cooperation is expected to result in physical or emotional harm of a serious nature to the parent, caretaker relative, or grantee sufficient to impair the caretaker’s ability to care for the child adequately; • The child was conceived as a result of incest or forcible rape; or • Adoption of the child is pendi ng before a court, or the caretaker is receiving pre- adoption counseling services (for up to three months after the child’s birth). W 6 childsupport.ny.gov In foster care cases, the foster care worker will determine the appropriateness of making a referral to the Child Support Enforcement Unit. The referral is legally prohibited under specific circumstances, including situations where the health, safety or welfare of the child or other children in the home will be adversely affected. The Child Support Enforcement Unit is required to safeguard the privacy, integrity, access to, and use of your personal information. This includes data obtained for a child support case that is kept in the child support program’s computer system. Any information given by you can be released SAFEGUARDING AND CONFIDENTIALITY OF PERSONAL IN FORMATION only to authorized persons for those reasons authorized by law Use of Social Security Numbers: Disclosure of the Social Security numbers of the custodial parent, noncustodial parent, putative father, and child are required by federal law (42 USC 666). The Child Support Enforcement Unit will use Social Security numbers only for the purpose of locating parents, establishing paternity, and/or establishing, modifying, and enforcing an order of support; for the admi nistration of certain public benefit programs; or as otherwise permitted by law. In addition, these Social Security numbers will be subject to verification through the Social Security Administration . . Support payments are distributed according to federal and New York State distribution rules. The distribution of support payments is based on the payment receipt date and as follows: DISTRIBUTION POLICY • If the custodial parent is receiving • If the custodial parent Temporary Assistance , child support collections received will be paid to the State and to the social services district for reimbursement of up to the total amount of Temporary Assistance that has been paid to the custodial parent. The custodial parent will be paid a child support “pass-through” from the current support coll ected each month in addition to the Temporary Assistance . The pass-through is an amount up to $100 per month of current support collected or up to the current support obligation amount, whichever is less, for any household with one individual under the age of 21 active on the Temporary Assistance case. The pass -through paid to the family increases to up to $200 per month of current support collected or up to the current support obligation amount, whichever is less, for Temporary Assistance families with two or more individuals under the age of 21 active on the Temporary Assistance case. The custodial parent will be paid any support collected after the total Temporary Assistance paid to the custodial parent has been reimbursed. former ly received • If the custodial parent Temporary Assistance , child support collections received will first be used to pay current support to the custodial parent followed by payments for support arrears/past due support owed to the custodial parent and then to support arrears/past due support due to the social services district for reimbursement of past assistance granted. However, collections received from federal tax refund offset will first be paid to satisfy any support arrears/past due support due the social services district fo r reimbursement of past assistance granted and then to support arrears/past due support owed to the custodial parent. The custodial parent will be paid any support collected after the total Temporary Assistance paid to the custodial parent has been reimbur sed. has never received • If the custodial parent Temporary Assistance, the custodial parent will receive all support that is collected and due, with the exception of the annual service fee and the recovery of costs for legal services, if applicable. is in receipt • If the child of Medicaid, medical support payments will be paid to the State and to the social services district for reimbursement of up to the total amount of Medicaid that has been paid to a provider. is in receipt SECTION 4 – LEGAL SERVICES AND COST RECOVERY of fo ster care, support collected will be paid to the social services district. Any support collected exceeding the foster care maintenance payments will be paid to the social services district supervising the child’s placement and foster care to use in the manner it determines will serve the child’s best interests. If your child does not receive Temporary Assistance or Medicaid, or your child is not in foster care, you may request legal services t o establish paternity or to establish, modify, or enforce a child support order . Please note that the services of an attorney are not necessarily required to proceed with a child support case. However, i f you request legal services, you will be advised by the Child Support Enforcement Unit of the cost of such services. The attorney assigned to your case is the legal representative of the Commissioner of the social services district and LEGAL SERVICES does not W 7 childsupport.ny.gov represent you personally. The attorney’s representation in this matter is limited to the establishment of paternity and the establishment, modification, adjustment, and enforcement of support obligations. Matters of custody, visitation, or other issues not related to child support will not be handled by the attorney of the social services district. Any information, written or oral, which you provide to the social services district’s attorney or staff may not remain confidential, including information indicating welfare fraud that must be reported to appropriate officials. If you have any questions concerning legal services , speak to a child support worker. If you wish to have your own legal representation, contact a legal services or legal aid organization for assistance or obtain the services of a private attorney of your own choosing at your own expense. Costs will be recovered by the Child Support Enforcement Unit for legal services that are provided upon completion of the Right to Recovery Agreement for Legal Services (LDSS-4920). COST RECOVERY FOR LEGAL SERVICES The Child Support Enforcement Unit will recover the cost a t the rate of 25% of your current support obligation from support collected, or if you are the noncustodial parent, the cost will be recovered at the rate of 25% of the current support obligation or payment you are required to make , and will be added to the support obligation that you pay until the cost is reimbursed. Each payment received by the Support Collection Unit will be credited to the account based on the distribution hierarchy described in Section 3 under Distribution Policy . This means that all s upport arrears/past due support will be paid in full before costs for legal services are settled. SECTION 5 – ANNUAL SERVICE FEE If the custodial parent is receiving child support services and has never received assistance through the TANF program (formerly Aid to Families with Dependent Children [AFDC]), in New York State or any other state and child support is being paid to the family SECTION 6 – PAYMENT AND CONTACT INFORMATION , an annual service fee of $25 will be imposed if more than $500 of support is collected during the federal fiscal year (October 1 – September 30). When $500 of support has been collected , the Support Collection Unit will automatically withhold the next $25 received during the federal fiscal year to pay the fee. If the custodial parent has accounts with more than one noncustodial parent and both noncustodial parents have paid in excess of $ 500, separate $25 fees will be imposed for each account. A pplicants/recipients do not have to pay the $25 fee for child support services received in regard to Medicaid or Safety Net Assistance, or for services provided for children placed in foster care , where child support is not paid to the family . Noncustodial parents primarily make child support payments through income withholding. However, noncustodial parents can make payments directly to the New York State Child Support Processing Center under certain circumstances (e.g., support order is newly established and income withholding has not yet taken effect, or the noncustodial parent is self -employed or does not have an employer). Payments can b e made with cashier’s checks, certified checks, and money orders. In addition, payments can be made through electronic funds transfer and by credit card. The Processing Center does not accept cash payments. Visit the New York State child support website at childsupport.ny.gov or call the New York State Child Support Customer Service Helpline at 888 -208- 4485 (TTY: 866- 875-9975) for further information on these payment methods. All payments must include the New York Case Identifier and be made payable to and sent to the : New York State Child Support Processing Center, PO Box 15363, Albany NY 12212- 5363. PAYMENT OPTIONS You may obtain answers to general child support related questions or y our account information by calling the New York Stat e Child Support Customer Service Helpline at 888 -208- 4485 (TTY: CUSTOMER SERVICE/ ACCOUNT INFORMATION 866-875-9975 – RETAIN PAGE 1 THROUGH PAGE 7 FOR YOUR RECORDS. SEPARATE THE APPLICATION/REFERRAL FOR CHILD SUPPORT SERVICES, PAGE A-1 THROUGH PAGE A-8, TO COMPLETE AND PROVIDE TO THE CHILD SUPPORT ENFORCEMENT UNIT. Relay Service http://www.fcc.gov/encyclopedia/trs -providers ) or online at childsupport.ny.gov. A personal identification number (PIN) is needed for the website and the New York State Child Support Customer Service Helpline. You can request a PIN by contacting the New York State Child Support Customer Service Helpline. W A-1 childsupport.ny.gov APPLICATION/REFERRAL FOR CHILD SUPPORT SERVICES Retain Page 1 through Page 7 for your records. Separate the Application/Referral for Child Support Services, Page A -1 through Page A -8, to complete and provide to the Child Support Enforcement Unit (CSEU) . If you need language assistance to complete this form, please visit the local CSEU so that translation and/or interpretation services can be provided. If you have any disabilities that prevent you from completing this form and/or waiting to be interviewed, please notify the CSEU. The agency will make appropriate efforts to provide reasonable accommodations for you. Section A – Applicant/Recipient Information Primary Language What is your primary language?  English  Spanish  Other (specify) ______________________________________________ _______ Safety Concerns Do you have reason to believe that by seeking an order for paternity or child support your safety or the safety of the child will be put at risk, or believe you have good cause not to cooperate with the CSEU?  Yes  No If “Yes,” STOP here and discuss your concerns with the CSEU. Relationship of the Applicant/Recipient to the Child Note: The custodial parent (CP) is the parent who the child lives with the majority (over 50%) of the time. The guardian is an individual who is not the parent, but has physical custody of at least one child under the age of 21. If the child lives with the guardian on a day -to-day basis , the guardian has physical custody of the child. Physical custody is different from legal or court -ordered custody. The noncustodial parent (NCP) is the parent who does not have primary care or custody of the child, but has a responsibility to pay child support. The putative father (PF) is the man who may be the child’s father, but who was not married to the child’s mother before the child was born and has not established that he is the father in a court proceeding or by an acknowledgment of paternity . The c hild is an individual under age 21 for whom support is sought . Other is an individual for whom no other listed choice applies. I ndicate your relationship to the child of the matter : I am the (check one):  Custodial Parent  Guardian  Noncustodial Parent  Putative Father  Child  Other __________________________ (Complete Parts I – III of Section A and Sections B and C) This is the:  Social services district (SSD) or Office of Children and Family Services (OCFS) Commissioner’s Foster Care (FC) Referral (Complete Section A, Parts II – IV, and Section B only. If support is sought from more than one NCP, a copy of Part II or an LDSS -4882B must also be completed for the other NCP). Go to Part II. Applicant/Recipient’s Child Support History  I have never received Child Support Services for the child.  I have received Child Support Services, but my case was closed on: Month _____________________, Year ________, in the County of ____________________, State of ________________________ ____.  I am in receipt of Child Support Services. My case is in the County of ________ __________________, State of ____________________________, Case Identifier _____________________________. Applicant/Recipient’s Temporary Assistance History Are you or were you ever in receipt of federal Title IV -A assistance, currently the Temporary Assistance for Needy Families (TANF) program and formerly the Aid to Families with Dependent Children (AFDC) program, in New York State or any other state?  Yes  No Enter the date you were last on assistance. Month/Day/Year _____ ___ _____ / ____ _____ ____ / ________ _____ Where did you receive assistance? County of ______________, State of ____________. Are you or were you ever in receipt of New York State’s Safety Net Assistance (formerly the Home Relief Program)?  Yes  No Enter the date you were last on assistance. Month/Day/Year ________ _____ / _ ____ ________ / __ ______ _____ Where did you receive assistance? County of _______________________________ ___ Part I – Custodial Parent (CP) or Guardian Information CP or Guardian Name First Middle Last Suffix Social Security Number (SSN) - - Individual Taxpayer Identification Number (ITIN) - - Date of Birth Month/Day/Year _____ / ______ / ______ Gender  Female  Male Race/Ethnic Affiliation (Optional)  Asian  Black or African -American  Hispanic or Latina(o)  Native American or Alaskan Native  Native Hawaiian or Pacific Islander  White, non- Hispanic  Other Primary Language What is the CP or guardian’s primary language?  English  Spanish  Other (specify) ___ _________________________________ _________________ W A-2 childsupport.ny.gov Part I – Custodial Parent (CP) or Guardian Information (Cont’d) Mail Received in Care of (If other than CP or Guardian ) First Middle Last Suffix Mailing Address (Current or last known as of ____ / ____ / ____) No. Street Floor/Apt./Suite City State Zip Country Residential Address (Current if different from Mailing) No. Street Floor/Apt./Suite City State Zip Country Phone Numbers Home ( ) Cell ( ) Work ( ) Other ( ) Contact Preference  Home  Cell  Work  Other Best Time to Call  Daytime  Evening Email Addresses Home Work Other Emergency Contact First Middle Last Suffix No. Street Floor/Apt./Suite City State Zip Phone Number ( ) Email Address Marital Status of CP to Noncustodial Parent (NCP)/ Putative Father (PF) Was the CP ever married to the NCP/PF?  Yes  No Date of Marriage _______ / _______ / _______ Place of M arriage City State Country Is the CP now separated from the NCP/PF?  Yes  No Date of Separation _______ / _______ / _______ Is the CP legally separated from the NCP/PF?  Yes  No Date of Legal Separation ______ / ______ / ______ Is a divorce from the NCP pending?  Yes  No Name of the C ourt __________________________ Is the CP legally divorced from the NCP/PF?  Yes  No Date of Divorce ________ / ________ / _______ Court Location No. Street Floor/Apt./Suite City State Zip Country Marital Status of CP to Someone Other than the NCP/PF Has the CP ever been married to someone other than the parent of the child named in this application?  Yes  No If “Yes,” provide the date(s) of marriage and name(s) of spouse below. From _____ / _____ / _____ to _____ / _____ / _____ Name of Spouse _____________________________________ From _____ / _____ / _____ to _____ / _____ / _____ Name of Spouse _____________________________________ CP’s Maiden Name CP Employer Information Employer Name Employer Address No. Street Floor/Apt./Suite City State Zip Country Health Care Coverage Information Does the CP’s employer/organization offer or provide health insurance benefits?  Yes  No  Unknown Is the CP enrolled?  Yes (specify):  Individual coverage  Family coverage  No  Unknown Is the CP or guardian enrolled in public health care coverage for a child named in this Application/Referral form?  Yes  No If “Yes,” indicate the type of public health care coverage:  Medicaid  Family Health Plus  Child Health Plus (CHPlus)  Other ___________ CP or guardian’s CHPlus monthly contribution : $ ________ W A-3 childsupport.ny.gov Part II – Noncu stodial Parent (NCP)/Putative Father (PF) Information If support for the child is sought from more than one NCP/PF at this time, an LDSS -4882B or a copy of this Part II must be completed for each additional NCP/PF. See Part III for information on how to obtain an LDSS -4882B. Copy of Part II or LDSS -4882B for additional NCP(s)/PF(s) attached NCP/PF Name First Middle Last Suffix Alias or Other Known Name Maiden Name SSN - - ITIN - - Date of Birth Month/ Day/Year ___ ___ / __ ____ / ______ Gender  Female  Male Race/Ethnic Affiliation  Asian  Black or African -American  Hispanic or Latina(o)  Native American or Alaskan Native  Native Hawaiian or Pacific Islander  White, non- Hispanic  Other Primary Language What is the NCP/PF’s primary language?  English  Spanish  Other (specify) ______________________________________ _________________ Description of the NCP/PF Height __ ft . _ _ _ in. Weight ______ ____ lbs . Eye Color Hair Color  Marks  Scars  Tattoos Describe: NCP/PF Father’s Full Name First Middle Last Suffix NCP/PF Mother’s Full Maiden Name First Middle Last Suffix NCP/PF’s Place of Birth City State Country Date of Last Contact Month/Day/Year _________ / _________ / ________ Relationship of NCP/PF to Applicant Note : This field is not applicable to FC cases. Mail Received in Care of (If other than NCP/PF) First Middle Last Suffix Mailing Address (Current or last known as of ____ / ____ / ____) No. Street Floor/Apt./Suite City State Zip Country Residential Address (Current if different from Mailing) No. Street Floor/Apt./Suite City State Zip Country Phone Numbers Home ( ) Cell ( ) Work ( ) Other ( ) Contact P reference  Home  Cell  Work  Other Best Time to C all  Daytime  Evening Email Addresses Home Work Other Emergency Contact First Middle Last Suffix No. Street Floor/Apt./Suite City State Zip Phone Number ( ) Email Address W A-4 childsupport.ny.gov Part II – Noncustodial Parent (NCP)/Putative Father (PF) Information (Cont’d) Incarceration Status Is the NCP/PF incarcerated?  Yes  No  Unknown Name of Facility Inmate Number Facility Address City State Zip Country Marital Sta tus of NCP/PF to Someone Other than the Custodial Parent (CP) or Other NCP for Foster Care (FC) case Was/is the NCP/PF married to someone other than the CP or Other NCP for a FC case?  Yes  No  Unknown If “Yes,” answer the following “Marital Sta tus of NCP/PF to Someone Other than the Custodial Parent (CP) or Other NCP for Foster Care (FC) case” questions. If “No” or “Unknown,” go to “NCP/PF Employment Information” questions below. Name of Spouse First Middle Last Suffix Address No. Street Floor/Apt./Suite City State Zip Country Phone Number ( ) Email Address Place of Marriage City State Zip Country Is the NCP/PF now separated?  Yes  No  Unknown Date of Separation ______ / ______ / ______ Is the NCP/PF legally separated?  Yes  No  Unknown Date of Legal Separation ____ / ____ / _____ Is a divorce pending?  Yes  No  Unknown Is the NCP/PF now divorced?  Yes  No  Unknown Date of Divorce _______ / _______ / _______ Court Location City State Zip Country NCP/PF Employment Information Is the NCP/PF employed?  Yes  No  Unknown Date Last Employed _______ / _______ / _______ Is the NCP/PF a member of a labor union/organization?  Yes  No  Unknown Name of E mployer Name of L abor Union/ Organization No. Street Floor/Apt./Suite No. Street Floor/Apt./Suite City State Zip City State Zip Country Phone Number ( ) Country Phone Number ( ) Job Title/ Occupation Job Title/ Occupation NCP/PF Health Insurance Information Does the NCP or PF’s employer/organization offer or provide health insurance benefits?  Yes  No  Unknown Is the NCP or PF enrolled?  Yes (specify):  Individual coverage  Family coverage  No  Unknown Additional Information about the NCP/PF W A-5 childsupport.ny.gov Part III – Child Information If the Custodial Parent (CP), Guardian, or Other Noncustodial Parent (NCP) for foster care (FC) cases has more than one child with this NCP/Putative Father (PF), an LDSS -4882C form or a copy of this Part III must be completed for each additional child. Forms can be downloaded from childsupport.ny.gov , requested by calling the N ew York State Child Support C ustomer Service Helpline at 888- 208-4485, or obtained by visiting the local Child Support Enforcement Unit. CIN _________ WMS Line Number _____ Copy of Part III or LDSS -4882C for each additional child attached Name of Child First Middle Last Suffix SSN - - ITIN - - Date of Birth Month/ Day/Year ____ / ____ / ____ Gender  Male  Female  Unborn Due Date ____ / ____ / ____ Name of Biological Parent Mother: First Middle Last Father: First Middle Last Relationship of the NCP/PF to the Child  Parent  Stepparent  Putative Father Parents’ Marital Status Was the mother married to the father or stepfather of the child at the time of the child’s birth?  Yes  No  Unknown If “Yes,” go to the “Order of Support Information” questions below. If “No” or “Unknown,” go to the “Paternity Establishment” ques tions below. Please note that if paternity was not established for the child, a paternity affidavit must be completed . Paternity Establishment Was paternity established?  Yes – G o to the “Paternity Establishment” questions below. You do not  No – G o to the “State of Jurisdiction” questions below. need to complete the “State of Jurisdiction” questions below.  Unknown – Go to the “State of Jurisdiction” questions below. How was paternity established?  Established in Court on _______ / _ _______ / ________ Name of C ourt ________________ _________________  Acknowledgment of Paternity on ______ / ___ __ / _____ In what county, state, and country was paternity established? County _________________________________________ State ___________________________________________ Country ___________________ ______________________ State of Jurisdiction Where was the child conceived? State _____________________________ Country ________________________ Did the PF provide prenatal expenses or support for the child?  Yes  No  Unknown Did the PF reside with the child in New York State?  Yes  No  Unknown Does the child reside in New York State as the result of acts or directives of the PF?  Yes  No  Unknown Order of Support Information Is there an order of support for this child?  Yes  No  Unknown If “Yes,” what is the date of the order? _________ / _________ / ________ Is health insurance ordered?  Yes  No  Unknown Obligation Amount $ ________  Weekly  Every two weeks  Monthly  Twice per month  Other ____________________________________________ Court that Issued the Order  Family Court  Supreme Court  Other County/State/Country Court Docket or Index Number Health Care Coverage Information Does the child have health care coverage?  Yes  No  Unknown If “Yes,” identify the type of coverage:  Private – Go to “Health Insurance Benefits” questions below.  Public – Go to “Public Health Care Coverage” question s below.  Unknown – Go to “Section B – Supporting Documentation” on page A -7. Health Insurance Benefits Who provides the child’s private health care coverage?  CP  Guardian  NCP/PF  Stepparent  Unknown  Other ________________________ Name of Health Insurance Carrier Policy Number Group Number No. Street Floor/Apt./Suite City State Zip Public Health Care Coverage Indicate the type of public health care coverage:  Medicaid  Family Health Plus  CHPlus  Other ____________________ Parent’s CHPlus monthly contribution: $ ________ W A-6 childsupport.ny.gov Part IV – Foster Care Information (Agency Use Onl y) Foster Care Referral The Commissioner or Designee must complete this section on behalf of the social services district (SSD) or the Office of Children and Family Services (OCFS) Commissioner for a child in Foster Care placement. Name of Child First Middle Last Suffix Case Information Case Number Case Status  Opening  Reopening  Changes or Updates Date of Referral _______ / _______ / ________ Category What is the claiming category?  IV -E Foster Care  Non -IV -E Foster Care Type of Placement  Voluntary  Court Ordered Placement Date _________ / _________ / _________ Cost of Care $ ___________ Per:  Day  Week  Month  Year Name of Agency, Facility, Foster Boarding Home County Agency Name Type of Facility Placement Address No. Street Floor/Apt./Suite City State Zip Subsidy Information Is an adoption subsidy received on behalf of the child?  Yes  No Does the subsidy include Medicaid?  Yes  No Subsidy Amount and When It Is Paid $ ________________ Per:  W eek  Month  Year Case Manager Name Phone Number ( ) Ext . Application for Child Support Services  I am applying for Child Support Services as the Commissioner or Designee and this is a Foster Care referral. Signature of Commissioner/Designee ________________________________________________ Date ___________________________________________________________________________________________ _ W A-7 childsupport.ny.gov Section B – Supporting Documentation You must provide copies of all available supporting documents to the Child Support Enforcement Unit (CSEU) for examination. CHECK ( ) the boxes indicating which documents you are providing. Copies of documents help the CSEU to establish paternity and establish, modify and/or enforce support. Supporting documentation also helps the court to make determinations regarding the incomes of the noncustodial parent (NCP) and the custodial parent (CP) and the amount of the basic child support obligation. Please do not send original documents in the mail. Documents in Su pport of Establishing Paternity and Establishing, Modifying and/or Enforcing Support  Birth Certificate of the Child  Order of Filiation  Marriage Certificate of the  CP and NCP/P utative F ather (PF)  NCP/PF and other NCP for F oster Care (FC) cases  Separation Agreement between the  CP and NCP/PF  NCP/PF and other NCP for FC cases  Divorce Decree for  CP and NCP/PF  NCP/PF and other NCP for FC cases  Paternity Acknowledgment  Affidavit Alleging Paternity  Order of S upport  Most recently filed Federal Tax Returns and all Schedules of  CP  NCP/PF  W -2s of  CP  NCP/PF  Adoption Subsidy Agreement  Adoption Placement Agreement  Pay Stubs of  CP  NCP/PF  Benefits Notice or Letter regarding  Temporary Assistance for Needy Families (TANF) or  Unemployment Benefits for  CP  NCP/PF  Award Letter regarding Social Security Disability for  CP  NCP/PF  Social Security Card or  IRS letter for Individual Taxpayer Identification Number (ITIN) for CP or Guardian  Social Security Card or  IRS letter for ITIN for N CP /PF  Award Letter regarding Supplemental Security Income (SSI) for  CP  NCP/PF  Award Letter regarding Social Security Retirement Income for  CP  NCP/PF  Military Service (DD- 214) of NCP/PF  Social Se curity Card or  IRS letter for ITIN for Child  Attestation to Lack of Information (LDSS - 4281)  Information Regarding NCP/PF’s Arrests Not Resulting in Incarceration  Information Regarding NCP/PF’s Probation or Parole  Information Regarding NCP/PF’s Driver License  Order of Protection  Information Regarding NCP/PF’s Professional, Business, Occupational or Recreational Licenses  Proof of Child Care E xpenses for the Child  Proof of Educational Expenses for the Child  Proof of Unreimbursed Health Care Expenses for the Child  Health Insurance Benefit Cards  Summary Plan Descriptions of Health Insurance Benefits W A-8 childsupport.ny.gov Section C – Application/Affirmation for Child Support Services The Child Support Enforcement Unit (C SEU) will provide paternity establishment, support establishment, modification, review and adjustment, support collection and disbursement, and enforcement services, as appropriate. C heck and s ign Box 1 if you are applying for child support services and you are not applying for or in receipt of Temporary Assistance or Medicaid. For Safety Net Assistance referrals, t he Commissioner or Designee of the social services district as the applicant for child support services must sign and print his or her name and enter the date under Box 1 . Check and s ign Box 2 if you are applying for or in receipt of Temporary Assistance or Medicaid. Box 1  I am applying for Child Support Services pursuant to New York State Social Services Law, Section 111- g. I hereby apply for child support enforcement services pursuant to New York State’s Social Services Law Section 111- g and under Title IV -D of the federal Social Security Act. I hereby subscribe and affirm under penalty of perjury that the information I have provided in the application and any accompanying documents has been examined by me and to the best of my knowledge and belief is true and correct. I agree to tell the Child Support Enforcement Unit immediately of any new or changed i nformation that relates to the information I have provided in this form.  Check this box if you wish to request legal services. A Right to Recovery Agreement for Legal Services ( LDSS- 4920) will be provided to you for completion. Signature of applicant for Child Support Services _______________________________________________ _ Print Name ___ ___________________________________________________ Date ________ __________ Signature of Commissioner or Designee of the social services district for a Safety Net Assistance referral _________________________________________ ____ Print Name ______________________________________________________ Date __________________ Box 2  I am applying for or receiving Temporary Assistance or Medicaid. I hereby subscribe and affirm under penalty of perjury that the information I have provided in the referral and any accompanying documents has been examined by me and to the best of my knowledge and belief is true and correct. I agree to tell the Child Support Enforcement Unit immediately of any new or changed information that relates to the information I have provided in this form. Signature of applicant/recipient for Temporary Assistance or Medicaid _________________________________ Print Name __________________________________ _____________________ Date ____________________ Agency Use Only Child Support Enforcement Unit/Support Collection Unit Representative (Print name) Date ____ ___ / __ ____ / ________ New York Case Identifier Worker Code  SSD Referral Case Number ____________ Worker Name ____________________ ___________________________ Worker Location ____________________________________ Worker Phone Number ___________________________  TANF/MA  MA -Only  Safety Net  Child Support Services Application (Non- TA)  Opening  Reopening  Changes or Updates Date of Application/Referral _____ / _____ / _______