Application For Services (Non-Custodian) Form. This is a Alaska form and can be use in Child Support Services Division Statewide.
Tags: Application For Services (Non-Custodian), 04-1017B, Alaska Statewide, Child Support Services Division
STATE OF ALASKA DEPARTMENT OF REVENUE CHILD SUPPORT SERVICES DIVISION NONCUSTODIAL PARENT’S APPLICATION FOR SERVICES You may complete an application to obtain Child Support Services Division (CSSD) services. CSSD can determine paternity, establish or modify child support and medical support orders, and enforce existing support orders, even if the parents live in different states. CSSD charges no fees, although the cost of determining paternity may be charged to the father. CSSD collects and distributes payments from noncustodial parents; payments are issued when they are received. When child support is established by CSSD in an administrative order, the amount is calculated based on the Alaska Supreme Court’s child support rule, Civil Rule 90.3. The application and the “Statement of Support Provided” must be completed and signed separately. Additional information about the application, your responsibilities, CSSD services, and public assistance is found on the next three pages of this application packet. If you have an existing order from the court or from a child support agency that mentions child support, visitation, parental rights, or child custody, include it with your application. If you have been the victim of domestic violence, you may ask that your location be kept confidential by completing the “Affidavit and Request for Address Confidentiality” on page 7. After you have submitted this application, your case will be set up within 20 days, but it may take 60 days or more to make progress toward establishing or enforcing an order. During that time, contact us if you have additional information or questions. Our automated KIDSLINE provides answers to common questions and allows you to access payment information and leave messages for caseworkers. Also, you may visit one of our offices or go to our web page at www.childsupport.alaska.gov for more information. Please let us know if you need assistance or other accommodations to use our services. KIDSLINE: (907) 269-6900 KIDSLINE Toll Free (in Alaska): 1-800-478-3300 TDD machine: (907) 269-6894 TDD machine Toll Free (in Alaska): 1-800-370-6894 Statewide – Main Office 550 W 7th Ave Suite 310 Anchorage AK 99501-6699 (907) 269-6900 Fairbanks 675 7th Ave Station J2 Fairbanks AK 99701-4531 (907) 451-2830 Southeast 240 Main Street, First Floor PO Box 110402 Juneau AK 9981-0402 (907) 465-5887 CSSD 04-1017B (Rev. 01/03/12) (10 pp.) Mat-Su 845 W Commercial Dr Wasilla AK 99654-6937 (907) 357-3550 Mailing address for payments CSSD PO Box 100380 Anchorage AK 99510- 0380 Noncustodian’s Application for Services Page 1 of 10 American LegalNet, Inc. www.FormsWorkFlow.com For office use only: Requested: ___________ Sent: ___________ Case #: ___________________________ Date Date Reinstatement/Existing/Other NONCUSTODIAN’S APPLICATION FOR CHILD SUPPORT SERVICES Please indicate which services you are applying for. You must provide all information necessary and attach complete copies of orders or documents relating to custody, support and paternity. DO NOT SEND ORIGINALS. Complete separate applications if there are different custodial parents. Support order establishment Enforcement of an existing order Paternity establishment Medical support order establishment Review, modification, and enforcement of an existing order INFORMATION ABOUT YOU (THE NONCUSTODIAN APPLICANT) PLEASE PRINT Full name________________________________ Birth or previous names used __________________________________ Birthdate _________ Birthplace ______________ SSN ________________ Driver’s license state and # _______________ Mailing address _____________________________________City____________________ State ___ Zip ______________ Residence address ___________________________________ City____________________ State ___ Zip ______________ Home phone _________________ Work phone ____________________ Email address ____________________________ Occupation_________________Employer_______________________________________ Work hours ________________ Does an attorney represent you in any matters related to the child or the custodian? Yes No If yes, provide the attorney’s name, address, and phone ________________________________________________________________ Are you a tribal or Alaska Native corporation member? Yes No If yes, which?_______________________________ Have you ever received public assistance such as ATAP (Alaska Temporary Assistance), TANF (Temporary Aid to Needy Families), AFDC, or Medicaid? Yes No If yes, indicate what type, when, in what state, and provide a case number if available __________________________________________________________________________________________ CHILDREN FOR WHOM YOU ARE REQUESTING SERVICES Child’s full name You are the mother Sex father Date and place of birth relative __________ Social security # Who does this child live with? other (explain) ________________________________________. ABOUT THE OTHER PARENT (THE PERSON WITH CUSTODY) Full name _____________________________________ Birth or previous names used ___________________________ Birthdate ____________ Birthplace ________________ SSN _____________ Driver’s license state and # ______________ Address Current Last known _____________________________ City________________ State _____ Zip __________ Home phone _____________Email _____________The person is a citizen of U.S. another country ______________ How is the person related to the child/children? _____________________________________________________________ CSSD 04-1017B (Rev. 04/27/10) (10 pp.) Noncustodian’s Application for Services Page 2 of 10 American LegalNet, Inc. www.FormsWorkFlow.com Height ______Weight _____ Hair color _____Eye color ______ Race____________ Marks, scars, tattoos____________ Employer______________________________________Work phone _________________ Work hours _______________ Usual occupation ____________________________ Union member? (name and local number) ______________________ Military: None Active Reserve Guard Tribal or Alaska Native corporation member? Retired Branch/unit _______ Last rank/grade _____ Yrs in service ____ Yes No Does the custodian have an attorney regarding child support? If yes, which corporation? ____________________________ Yes No If yes, who?__________________________ Have you, the children, or the custodian ever received public assistance such as ATAP (Alaska Temporary Assistance), TANF (Temporary Aid to Needy Families), AFDC, or Medicaid? Yes No If yes, indicate what type, when, in what state, and provide a case number if available ________________________________________________________________ RELATIONSHIP BETWEEN THE CUSTODIAN (THE OTHER PARENT) AND YOU Divorced Date________ City/state ______________________ Attach a complete copy of the divorce decree or order. Case number _________ Married but separated Marriage date/place ______________________________ Separation date ________ Divorce/Dissolution pending Date filed City/State ______________________ Court case number _______ Separation date ____________________ Never married Separation date_____________________ Complete the following. Attach a birth certificate for each child. Add pages if needed. Yes No Child: _____________ Did the father sign an Affidavit of Paternity? Yes No Is the father’s name on the birth certificate? In what state was the birth certificate issued? ___________________ Yes No Child: _____________ Did the father sign an Affidavit of Paternity? Yes No Is the father’s name on the birth certificate? In what state was the birth certificate issued? ____________________ Other (explain) _____________________________________________________________________________________ OTHER INFORMATION Check here if you have been a victim of domestic violence and you want your address kept confidential from the other party. Please submit an “Affidavit and Request for Address Confidentiality.” The form is included in this packet. Check here if you have had a child support case in Alaska or another state, and explain: For which child?_____________ In what state/county? _____________________ Do you know the case number? __________________________ Check here if the child is eligible for Indian Health Service, military, or other medical or health coverage and explain: Which child? ________________________ Eligibility through which parent? _____________________________ Type of coverage? ____________________________________________________________________________ Your signature is required before CSSD can process this case. Include complete copies of all orders or documents relating to custody, support, or paternity. Do not send original documents. You must complete the Statement of Support Provided. You must complete the confidentiality affidavit if you want your address kept confidential. Applicant's signature: ________________________________________ Date: _____________________ Return the completed application, the statement of support received and all supporting documents to: Child Support Services Division 550 W 7th Ave., Ste. 310 CSSD 04-1017B (Rev. 04/27/10) (10 pp.) Anchorage AK 99501-6699 Noncustodian’s Application for Services Page 3 of 10 American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Completing the Statement of Support Provided 1. Enter your name, the CSSD case number (if you have a CSSD case already and you know the number) and the name of the custodial parent or custodian. If there are different custodians for different children, please submit a separate statement for each child. 2. Enter the full name and date of birth for each child. 3. If there is an administrative support order from Alaska or another state, check the first option. If there is a court order, check the second option, and indicate whether the court order includes child support, alimony (spousal support), or both. If there is both a court order and an administrative order, check both the first and second options. If there is no order of any kind, check the third option. 4. If you have provided child support to the custodial parent, check the first option and complete the “Child Support” columns in the table. Don’t forget to indicate the year(s). See example below. If you have provided some child support, but you are not sure when or how much, check the second option and enter your estimates in the table (marked “estimates”) or on a separate page. If you have provided no child support at any time, check the third option. NOTE: If the custodial parent or the child is receiving government benefits from Social Security, the Veterans Administration, or another government agency, and the benefits are based on your disability or your service or retirement, these benefits may be credited toward your support obligation. Please provide information about such benefits on a separate page. 5. If you have provided alimony or spousal support to the custodial parent, check the first option and complete the “Alimony/Spousal” column in the table. Don’t forget to indicate the year(s). See example below. If you provided some spousal support, but you are not sure when or how much, check the second option and enter your estimates in the table (marked “estimates”) or on a separate page. If you have provided no alimony or spousal support at any time, check the third option. 6. If a child support order is already in effect, and you lived with the other parent or you had custody of the child or children at any time since the child support order took effect, check the “Yes” box and attach a written explanation Table: Start with the first month and year you were supposed to provide support, and continue through the current month and year. Add additional pages, if necessary. Enter “0” in months when no support was provided. For example, if the child support order says you should have paid $250 child support per month beginning in June of 2000, and no spousal support, but you were not able to pay regularly and or in full, your “support provided” table might look like this in December 2001: Year 2000 Jan Child Support N/A Alimony/ Spousal N/A Year Child Alimony/ 2001 Jan Support Spousal $0 N/A Feb May $0 May Apr $50 Apr Mar $75 Mar Feb $0 Jun $100 Jun $75 Jul 0 Jul $175 Aug $150 Aug 0 Sep $150 Sep 0 Oct 0 Oct $200 Nov $225 Nov $100 Dec $175 Dec $0 CSSD 04-1017B (Rev. 04/27/10) (10 pp.) Noncustodian’s Application for Services Page 4 of 10 American LegalNet, Inc. www.FormsWorkFlow.com STATEMENT OF SUPPORT PROVIDED See previous page for instructions. If you provided no support, check the “no support provided” boxes in Items 4 and 5, and sign the next page. 1. Your name: ____________________ CSSD case # __________Custodial parent’s name ______________________ 2. You are the noncustodial parent of these minor children: Child’s full name Date of birth Child’s full name Date of birth Check all the appropriate boxes in items 3-6, and complete the table below (or submit separate statements regarding estimates, as necessary). Sign the next page. 3. 4. 5. An administrative order from CSSD or another child support agency requires you to pay child support. List in the table below the child support you have paid to the custodial parent. Don’t forget to indicate the year. List in the table below the alimony (spousal support) you have paid to the custodial parent. Don’t forget to indicate the year. OR OR OR A court order requires you to pay: child support alimony (spousal support) If you aren’t sure how much child support you’ve paid the custodial parent, list your best estimate by month and year in the table below (or on a separate page) If you aren’t sure how much alimony (spousal support) you’ve paid the custodial parent, list your best estimate by month and year below (or on a separate page) OR No administrative or court order for child support is in effect at this time. OR You have paid no child support to the custodial parent. OR You have paid no alimony (spousal support) to the custodial parent. 6. If a child support order is already in effect, did you live with the other parent (or have you had custody of the children) at any time since that order was issued? Yes No If your answer is “Yes,” attach a description of the time periods when the two of you lived together (or when you had custody) since the child support order was issued. In the following table, enter only support that was PROVIDED, not support that was DUE. Year: Child Support Alimony/ Spousal Jan Feb Mar Apr May Jun July Aug Sep Oct Nov Dec Year: Jan Feb Mar Apr May Jun July Aug Sep Oct Nov Dec Child Support Alimony/ Spousal Year: Child Support Alimony/ Spousal Jan Feb Mar Apr May Jun July Aug Sep Oct Nov Dec (Continued on the next page, where your signature is required.) 1606 (CSSD 04-1017B Rev. 04/27/10) (10 pp.) Noncustodian’s Application for Services Page 5 of 10 American LegalNet, Inc. www.FormsWorkFlow.com Statement of Support Provided continued Year: Child Support Alimony/ Spousal Jan Feb Mar Apr May Jun July Aug Sep Oct Nov Dec Year: Child Support Alimony/ Spousal Jan Feb Mar Apr May Jun July Aug Sep Oct Nov Dec Child Support Alimony/ Spousal Jan Feb Mar Apr May Jun July Aug Sep Oct Nov Dec Year: Year: Year: Alimony/ Spousal Jan Feb Mar Apr May Jun July Aug Sep Oct Nov Dec Year: Jan Feb Mar Apr May Jun July Aug Sep Oct Nov Dec Signature ____________________________________ 1606 (CSSD 04-1017B Rev. 04/27/10) (10 pp.) Alimony/ Spousal Jan Feb Mar Apr May Jun July Aug Sep Oct Nov Dec Child Support Alimony/ Spousal Jan Feb Mar Apr May Jun July Aug Sep Oct Nov Dec Child Support Year: Child Support Year: Child Support Alimony/ Spousal Jan Feb Mar Apr May Jun July Aug Sep Oct Nov Dec Child Support Alimony/ Spousal Year: Child Support Alimony/ Spousal Jan Feb Mar Apr May Jun July Aug Sep Oct Nov Dec Date _________________________ Noncustodian’s Application for Services Page 6 of 10 American LegalNet, Inc. www.FormsWorkFlow.com Affidavit and Request for Nondisclosure of Identifying Information Complete this affidavit only if you want your address and information about your location to be kept confidential and not released to a person (such as a parent or custodian) who would otherwise be entitled to have the information. CSSD will respond in writing with a decision about your request for confidentiality. I, ______________________________________________, swear under penalty of perjury that the following information is true to the best of my knowledge and belief: Name of person I do not want information released to: __________________________ Person’s relationship to me or the child: __________________ CSSD case number: _____________ Please check all that apply: 1. This person has committed domestic violence (threatened, harassed, physically or mentally abused, or committed sexual assault or incest) against me or my child. 2. A domestic restraining or violence protective order has been issued against the person. 3. The person has been charged with a crime (such as assault or harassment) or been involved in a criminal civil or criminal court case in which I was a party, a victim, a witness, or otherwise involved. If you checked any of the above please explain what happened, when, where and who was involved. _______________________________________________________________________________________________________________ _________________________________________________________________________________________________________ If you checked # 2 or 3, please indicate the Court location and case number:_______________________ If you did not check any of the boxes above, please explain why you feel threatened by this person. _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _________________________________________________________________________________________________________ If you need additional space for your answers, please use the back of this page. Signature ______________________________ Date__________________________ SUBSCRIBED and SWORN to before me this _________ day of _______________________, 20 ______ ________________________________________ Notary Public for the State of __________ My commission expires _______________ If you can’t get to a notary, please sign before a witness and have the witness complete the information below. I know the person who signed this form is the person he or she claims to be, and I witnessed the signature above. Witness signature ___________________________________________ Witness address _____________________________________________ CSSD MAILING ADDRESS: 550 W 7th AVE SUITE 310 0502 (CSSD 04-1017B Rev. 04/27/10) (10 pp.) Witness name (please print) ______________________ Witness phone ________________________________ ANCHORAGE AK Noncustodian’s Application for Services 99501-6699 Page 7 of 10 American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com STATE OF ALASKA DEPARTMENT OF REVENUE CHILD SUPPORT SERVICES DIVISION INFORMATION ABOUT CHILD SUPPORT SERVICES Child Support Services Division You are required to provide your social security number to CSSD. This is mandatory under federal law at 42 USC Section 405 (c)(2)(C). Your social security number will be used by CSSD to identify and locate you for the purposes of establishing paternity and establishing, modifying and enforcing support obligations. You will be asked for your social security number when you call CSSD so we can identify your case. We may also ask for your social security number on forms you may need to complete in order for CSSD to help you. CSSD provides child support services for parents or third-party custodians. CSSD can: collect and mail out child support payments; establish paternity when necessary; establish child support and medical support orders; enforce child support orders, even if the paying parent is not in Alaska; modify support orders if there is good reason; require banks, employers, the Permanent Fund, and others to withhold the paying parent’s income or assets; attach IRS tax refunds to collect child support; and provide interstate services when parents move to other states. Enforce medical support orders There is no fee for these services, although costs related to determining paternity may be charged to the father. CSSD cannot monitor or modify visitation or custody orders; a court must address those matters. Child Support Payments Support orders established by CSSD begin with the month CSSD receives the application, unless the children received public assistance earlier. Once CSSD receives an application, all support payments must be made through CSSD unless a court order specifically provides otherwise. If a custodian receives a direct payment before the case is set up, the custodian must notify CSSD, in writing, how much was received and when. Money collected by CSSD is paid first to the custodian, unless the custodian or the child is receiving or has received public assistance. In those cases, the state debt must be repaid. Establishing Paternity If paternity has not been established and child support is requested, CSSD will establish paternity. This generally occurs when a child is born to unmarried parents. If the child was born in Alaska, parents can contact the Bureau of Vital Statistics to complete an affidavit if they agree about paternity. However, if the child was born in another state, and the parents want to complete an affidavit of paternity, they must contact that state for assistance. If they disagree, CSSD will require genetic tests to determine paternity. The man who proves to be the biological father may be required to pay for genetic tests and related costs. CSSD 04-1017B (Rev. 04/27/10) (10 pp.) Noncustodian’s Application for Services Page 8 of 10 American LegalNet, Inc. www.FormsWorkFlow.com Establishing Support Orders CSSD calculates child support using the Child Support Guidelines in Alaska Supreme Court Rule of Civil Procedure 90.3. This rule requires that the child support obligation be a percentage of the adjusted annual income of the noncustodial parent based on the number of children in the support order. Parties can ask for exceptions. If a parent does not provide income information, CSSD will use the best information available to determine the parent’s income from all sources. We use an “Administrative Child Support Order” when we issue a child support or medical support order. Either party can appeal the findings in that order and present evidence. Either party may appeal the CSSD decision to the Office of Administrative Hearings Administrative Law Judge. Either party may then appeal the Administrative Law Judge’s decision to the superior court. Enforcing Support Orders If child support is owed and CSSD identifies the noncustodial parent’s employer, bank account, or other financial account, we normally issue an Order to Withhold and Deliver those wages or assets. The withholding order is a standard method of ensuring timely support payments. Support is withheld directly from the payroll office or the bank account. Noncustodial parents who want to make additional payments, or who are self-employed, may pay by check or money order (please include the case number) to the payment mailing address (see the cover sheet of this application). Cash payments can be made only in person, and only in the Anchorage office. Failure to pay support may result in collection actions including liens, judgments, withholding from Permanent Fund Dividends, wages, or other income, credit bureau reporting, the seizure of bank and financial accounts, and other civil and criminal law actions. Noncustodial parents who owe more than four months of child support may lose their occupational licenses or their driver’s licenses. Noncustodial parents who owe $2,500 or more in past child support (arrears) risk losing their passports. We file liens on real estate if arrears are at least $2,500 or equal to one year’s support. CSSD may take the noncustodial parent’s federal income tax refunds to pay past due support. If the custodian received public assistance in Alaska, the IRS refund is applied first to reimburse the state. IRS funds remaining after the state is paid go to the custodian. Modifying Support Orders Either party, or the state, has the right to request a review of a child support order. Both parties must provide financial information to CSSD. Private agreements between parties are not valid unless approved by the court. Situations that could result in support modification are: a child listed in the order has reached the age of majority or been legally emancipated; the child support guidelines were adopted or significantly amended after the support order was issued; the obligor’s income has changed to the extent that support would change by 15 percent; or medical support or post-majority support language is needed in the order. If a court issues a support order, usually the court must modify the order. If CSSD or another child support Enforcement agency issues an administrative support order, the agency can modify it. Your Rights and Responsibilities Alaska law allows interest to be charged on payments received ten or more days past the due date, on judgments, and on most arrears. If you use CSSD services, you must notify us immediately of the following: address changes; permanent custody changes visitation when there is a court order for visitation; new employment or changes in earnings; American LegalNet, Inc. www.FormsWorkFlow.com availability of medical insurance coverage for the children; any action by the parties that may affect support (such as seeking a new or modified court order, custody changes, adoptions, bankruptcy, or other collections). We invite parties to attend and participate in case proceedings and hearings to protect their interests. An Assistant Attorney General represents CSSD in child support hearings; parties may hire attorneys at their own expense. Medical Support Federal and state laws require parents to provide medical support for their minor children. CSSD will provide medical support services to the applicant. Those services will include establishment, modification and enforcement of support orders that include health insurance provisions and cash medical support, in addition to regular child support. Credit for health care coverage may raise or lower the amount of ongoing child support, depending on which parent provides the coverage. Health insurance benefits available through the Indian Health Service or the military may satisfy the medical support requirement. Custodians who receive only Medicaid must assign to the state their medical insurance benefits or any fixed amounts of cash medical support the noncustodial parent is ordered to pay. Public Assistance If the custodian receives public assistance through ATAP (the Alaska Temporary Assistance Program, which replaced AFDC), through another state’s welfare program (such as those funded through TANF, the federal Temporary Aid for Needy Families program) or through Medicaid or Denali KidCare, we automatically provide services without requiring a CSSD application. In ATAP or TANF cases, child support must be assigned to the state. This means the state will keep the child support received up to the amount of public assistance paid out. Enforcement cannot stop while public assistance is being received, while the children are in licensed foster care, or if the other party applies for services. If the custodian receives only Medicaid or Denali KidCare and does not want cash support, CSSD must be notified. We will continue to enforce only the medical support order. If all public assistance ends, CSSD services will stop upon the custodian’s written request, although enforcement to recover money owed to the state may continue. Requesting Confidentiality The Child Support Services Division may be required to release information about you or your children to other parties or agencies. Information that may be released may include names, addresses, social security numbers, and birth dates. This information will be released only when authorized by law and only as needed to take action on your case. This information will not be released to the general public. However, if your case is filed in court, information in the court case may be available to the public. If you or your children have been victims of domestic violence, including harassment, threats, mental and emotional abuse, physical violence including sexual assault or incest, and parental kidnapping, you may ask that information about your address and location be kept confidential. You must complete the “Affidavit and Request for Address Confidentiality,” sign it before a notary or a witness, and return it within 30 days. Attach any documents you have (such as police reports, protective orders, restraining orders, or medical records) to show why you believe the release of information about your address or your location would threaten your well being. We will review your request and get back to you in writing. Please contact us if you have questions. CSSD addresses and phone numbers are on the cover sheet of this application. American LegalNet, Inc. www.FormsWorkFlow.com