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 TDD machine: (907) 269-6894 Statewide ­ Main Office 550 W 7th Ave Suite 310 Anchorage AK 99501-6699 (907) 269-6900 KIDSLINE Toll Free (in Alaska): 1-800-478-3300 TDD machine Toll Free (in Alaska): 1-800-370-6894 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 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.) 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 PLEASE PRINT INFORMATION ABOUT YOU (THE NONCUSTODIAN APPLICANT) 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 Sex Date and place of birth Social security # Who does this child live with? You are the mother father relative __________ 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 __________ U.S. another country ______________ Page 2 of 10 American LegalNet, Inc. www.FormsWorkFlow.com Home phone _____________Email _____________The person is a citizen of CSSD 04-1017B (Rev. 04/27/10) (10 pp.) How is the person related to the child/children? _____________________________________________________________ Noncustodian's Application for Services 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 Retired Branch/unit _______ Last rank/grade _____ Yrs in service ____ Yes No If yes, which corporation? ____________________________ Yes No If yes, who?__________________________ Tribal or Alaska Native corporation member? Does the custodian have an attorney regarding child support? 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