CHILD SUPPORT SERVICES VERIFICATION FORM TO: CSSD FROM: Phone: (907) 269-6900 option 5 Phone: FAX: (907) 787-3310 FAX: I, grant you permission Type or Print Name of person social security number to disclose the amount of my benefits to Type or print the name of your agency Signature of person 1. Declaration of Payment Received through Child Support Services Division if ordered by a divorce decree, administrative order, or judgement. The Child Support Services Division (CSSD) shall fill out this section if disbursements are being paid directly to the applicant through CSSD or payments are being made through CSSD. Child support case number ________________ Child support case number _________________ Monthly Child Support charged _________ Monthly Spousal support charged _________ Other _________ Monthly Child Support charged Monthly Spousal support charged Other _________ _________ _________ Please attach last 12 months payment record received by custodial parent. Please attach last 12 months payment record received by non-custodial parent. Comments:______________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ____________________ ___________ __________ ___________ Name of person completing form Title Phone number Date 04-0950 (Rev 5/3/06)