Custodians Application For Services Form. This is a Alaska form and can be use in Child Support Services Division Statewide.
Tags: Custodians Application For Services, 04-1017, Alaska Statewide, Child Support Services Division
STATE OF ALASKA DEPARTMENT OF REVENUE CHILD SUPPORT SERVICES DIVISION CUSTODIAN’S APPLICATION FOR SERVICES Custodial parents and other custodians must complete an application for services to obtain Child Support Services Division (CSSD) services. CSSD can then establish paternity, establish child support and medical support orders, and enforce or modify existing support orders, even if the non custodial parent lives in another state. CSSD charges no fees, although the cost of determining paternity may be charged to the father. CSSD collects and distributes payments from non custodial parents; we do not provide the child support funds. When child support is established by CSSD in an administrative order, the amount is calculated based on the Alaska Supreme Court child support rule, Civil Rule 90.3. The application and the “Statement of Support Received” 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 an existing order from a court, from CSSD, or from another child support agency mentions child support, custody, visitation, or parental rights, include it with your application. If you or your children have been victims of domestic violence, you may ask that your location be kept confidential by completing the “Affidavit and Request for Address Confidentiality” on page 11. After you have submitted your application, your case will be set up within 20 days. 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 important 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 04-1017 (Rev. 01/03/12) (12 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 Custodian’s Application for Services Page 1 of 12 American LegalNet, Inc. www.FormsWorkFlow.com STATE OF ALASKA DEPARTMENT OF REVENUE CHILD SUPPORT SERVICES DIVISION INFORMATION ABOUT CHILD SUPPORT SERVICES Child Support Services 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 distribute child support payments; establish paternity; 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 the costs of 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 provides otherwise. If a custodian receives a direct payment before the case is set up, the custodian must tell CSSD, in writing, how much was received and when. Money collected by CSSD is paid 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. If the child was born in another state, 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 04-1017 (Rev. 01/03/12) (12 pp.) Custodian’s Application for Services Page 2 of 12 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 non custodial 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. After an administrative review, we may change those findings. 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 non custodial 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. Non custodial parents who want to make additional payments, or who are selfemployed, may pay by check or money order. Please include the case number with the payment, and send it to the payment mailing address (see the cover sheet of this application). Cash payments can be made only in person, and only in Anchorage. 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. Non custodial parents who owe more than four months of child support may lose their occupational licenses or their driver’s licenses. Non custodial 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 non custodial parent’s federal income tax refunds to pay arrears. 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 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, new employment, or changes in earnings; permanent custody changes; CSSD 04-1017 (Rev. 01/03/12) (12 pp.) Custodian’s Application for Services Page 3 of 12 American LegalNet, Inc. www.FormsWorkFlow.com visitation when there is a court order for visitation; payments received directly from the non custodial parent; availability of or changes in health care 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 non-custodial 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 or 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” on page 11, 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. The CSSD addresses and phone numbers are on the cover sheet of this application. CSSD 04-1017 (Rev. 01/03/12) (12 pp.) Custodian’s Application for Services Page 4 of 12 American LegalNet, Inc. www.FormsWorkFlow.com For office use only: Requested: ___________ Sent: ___________ Case #: ___________________________ Date Date Reinstatement/Existing/Other APPLICATION FOR CHILD SUPPORT SERVICES Please indicate which services you want. You must provide all information necessary for these services. Attach complete copies of orders or documents relating to custody, support and paternity. DO NOT SEND ORIGINALS. Support order establishment Paternity establishment Medical support order establishment Enforcement of an existing order Review, modification, and enforcement of an existing order INFORMATION ABOUT YOU (THE APPLICANT) PLEASE PRINT Full name__________________________________ Birth/previous/other names _______________________________ Date of Birth _______________ Birthplace ________________________________ SSN ________________________ Mailing address _____________________________________City____________________ State ____ Zip __________ Home address _______________________________________ City____________________ State ____ Zip __________ Driver’s license state and # _________________Home phone ________________Email address ___________________ Employer____________________________________Work phone _________________ Work hours _______________ Does an attorney represent you in any matters related to the child or the other parent? Yes No If yes, provide the attorney’s name, address, and phone __________________________________________________________ Have you ever received public assistance such as ATAP (Alaska Temporary Assistance), TANF (Temporary Aid to Yes Needy Families), AFDC, or Medicaid? No If yes, indicate what type, when, in what state, and provide a case number if available _________________________________________________________________________________ CHILDREN YOU ARE SEEKING SUPPORT FOR (add pages if necessary) Child’s full name You are the mother Sex father Date and place of birth relative __________ SSN Who does this child live with? legal custodian by court order (explain)__________________ NONCUSTODIAL PARENT YOU ARE SEEKING SUPPORT FROM Full name ______________________________________ Birth/previous/other names ___________________________ Date of Birth _________________ Birthplace ________________________________ SSN _______________________ Address Current Last known _________________________________________________________________ City_________________________ State _____ Zip __________ Driver’s license state and # ______________________ Home phone _________________ Email _________________ Citizen of CSSD 04-1017 (Rev. 01/03/12) (12 pp.) U.S. Custodian’s Application for Services other country ________________ Page 5 of 12 American LegalNet, Inc. www.FormsWorkFlow.com How is the person related to the child? __________________________________________________________________ Height ______Weight _____ Hair color _____Eye color ______ Race__________ Marks, scars, tattoos____________ Does/did the person live or work in Alaska? Yes No If yes, where and when? _____________________________ Does the person have relatives in Alaska? Who and where? _________________________________________________ Usual occupation __________________________ Union member? (name and local number) ______________________ Current or most recent employer(s) Military Service: None Employer address Active Reserve Employer phone Guard Dates of employment Retired Branch/unit ______________________ Last rank/grade _______________ Yrs in service __________ Tribal or Alaska Native corporation member? Yes No Does this person have an attorney regarding child support? If yes, which corporation? _________________________ No Yes Who? ______________________________ Does or did the person receive (or does the person expect future) cash gifts, settlements, or awards? _________________ _________________________________________________________________________________________________ Other information that may be helpful in obtaining support (for example, bank accounts, stocks, property, pension, or other sources of income) ____________________________________________________________________________ RELATIONSHIP BETWEEN THE PARENTS Divorced Date of separation _____________________ Date of divorce _________________ Court case number ________________________________ City/County/State__________________________________ Attach a complete copy of the divorce decree/order. Married but separated Marriage date/place ___________________ Separation date ___________________ Divorce/Dissolution pending Date filed _____________________ Separation date _______________________ City/County/State_____________________ Court case number_________________ Never married Separation date (if parents lived together) _________________________________ Complete the following. Attach a birth certificate for each child. Child: _____________ Did the father sign an Affidavit of Paternity? Yes No Is the father’s name on the birth certificate? Yes No* In what state was the birth certificate issued? _______________ Child: _____________ Did the father sign an Affidavit of Paternity? Yes No Is the father’s name on the birth certificate? Yes No* In what state was the birth certificate issued? _______________ Child: _____________ Did the father sign an Affidavit of Paternity? Yes No Is the father’s name on the birth certificate? Yes No* In what state was the birth certificate issued? _______________ *If no, complete page 12 Other (explain) __________________________________________________________________________________ CSSD 04-1017 (Rev. 01/03/12) (12 pp.) Custodian’s Application for Services Page 6 of 12 American LegalNet, Inc. www.FormsWorkFlow.com OTHER INFORMATION Check here if you have been a victim of domestic violence and you want your address to be kept confidential from the other party. Please submit an “Affidavit and Request for Address Confidentiality” (see page 11). Check here if you agree that if CSSD sends a child support payment to you in error, you want to repay the overpayment gradually out of future child support payments (instead of immediately in a lump sum). CSSD will provide child support services to you even if you don’t agree to repay overpayments from future payments. Check here if you have or 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 health care coverage, and explain: Which child? ______________________ Eligibility through which parent? ______________________________________ Type of coverage? ______________________________________________________________________________ Include a complete copy of all orders relating to custody, support, and paternity. Do not send original documents. Complete the Statement of Support Received even if you receive no support. Complete the confidentiality affidavit if you want your address withheld from the other party. Your signature is required before CSSD can process this case. Applicant's signature: ________________________________________ Date: _____________________ Return the completed application, the statement of support received, the confidentiality affidavit (if needed) and all supporting documents to: Child Support Services Division 550 W 7th Avenue Suite 310 Anchorage AK 99501-6699 CSSD 04-1017 (Rev. 01/03/12) (12 pp.) Custodian’s Application for Services Page 7 of 12 American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Completing the Statement of Support Received 1. Enter your name and the non custodial parent’s name. Include the CSSD case number if you have a case already. 2. Enter the full name and date of birth for each child in your custody. 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 received child support from the non custodial parent, check the first option and complete the “Child Support” column in the table on the bottom of the page. Don’t forget to indicate the year(s). See example below. If you have received 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 received 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 the non custodial parent’s disability or retirement, these benefits may be credited toward the non custodial parent’s support obligation. Please provide information about such benefits on a separate page. 5. If you have received alimony or spousal support from the non 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 have received 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 received 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 the other parent had custody of the child at any time since the child support order took effect, please check the “Yes” box and attach a written explanation Table: Enter only the support you have received in this table. Do not enter support owed. Start your entries with the first month and year you were supposed to receive support, and continue through the current month and year. Enter “0” in months when support was due but no support was received. Add additional pages, if necessary. For example, if the child support order says you should have received $250 child support per month beginning in June of 2000, and no spousal support, and the custodial parent paid irregularly and never paid the full monthly child support amount, your “support received” table might look like this in December 2001: Year 2000 Jan Child Support Alimony/ Spousal N/A 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 04-1017 (Rev. 01/03/12) (12 pp.) Custodian’s Application for Services Page 8 of 12 American LegalNet, Inc. www.FormsWorkFlow.com STATEMENT OF SUPPORT RECEIVED See previous page for instructions. If you received no support, please check “no support received” and sign the next page. 1. Your name: ______________________ CSSD case # __________Non custodial parent’s name ______________________ 2. You are the custodian of these minor children: Child’s full name Date of birth Child’s full name Date of birth Check the appropriate boxes in items 3-6, and complete the table below (or submit separate estimates, as necessary). 3. An administrative order from CSSD or another child support OR agency directs that you are entitled to receive child support. 4. 5. List in the table below the child support payments you have received directly from the non custodial parent. Don’t forget to indicate the year. List in the table below the alimony (spousal support) you have received directly from the non custodial parent. Don’t forget to indicate the year. OR OR A court order directs that you are entitled to receive child support alimony (spousal support) If you aren’t sure how much child support you’ve received from the non 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 received from the non custodial parent, list your best estimate by month and year in the table below (or on a separate page) OR No administrative or court order for child support is in effect at this time. OR You have received no child support from the non custodial parent. OR You have received no alimony (spousal support) from the non custodial parent. 6. If a child support order is already in effect, did you live with the other parent (or has the other parent had custody of the Yes No If your answer is “Yes,” attach a description of the time children) at any time since that order was issued? periods when you lived together (or when the other parent had custody) since the child support order was issued. Enter only support received in the following table. Do not enter support due. Year: Jan Feb Mar Apr May Jun July Aug Sep Oct Nov Dec Child Support Alimony/ Spousal 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 04-1017 Rev. 04/27/10) (12 pp.) Custodian’s Application for Services Page 9 of 12 American LegalNet, Inc. www.FormsWorkFlow.com Statement of Support Received continued 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 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 Year: Child Support Alimony/ Spousal Alimony/ Spousal Year: Child Support Alimony/ Spousal Child Support Alimony/ Spousal Jan Feb Mar Apr May Jun July Aug Sep Oct Nov Dec Child Support Jan Feb Mar Apr May Jun July Aug Sep Oct Nov Dec Alimony/ Spousal Year: Jan Feb Mar Apr May Jun July Aug Sep Oct Nov Dec Signature __________________________________ 1606 (CSSD 04-1017 Rev. 04/27/10) (12 pp.) Child Support Jan Feb Mar Apr May Jun July Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun July Aug Sep Oct Nov Dec Child Support Year: Custodian’s Application for Services Date ____________________ Page 10 of 12 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 name (please print) __________________________________ Witness address _______________________________________________Witness phone ________________________________ CSSD MAILING ADDRESS: 550 W 7th AVE SUITE 310 0502 (CSSD 04-1017 Rev. 04/27/10) (12 pp.) ANCHORAGE AK Custodian’s Application for Services 99501-6699 Page 11 of 12 American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com PATERNITY WITNESS STATEMENT CSSD Case No: __________________________ A separate statement is required for each child whose paternity must be established (use the back of the form for detailed explanations) I, ____________________, am the natural mother of (child’s name - first, middle, last) ___________________________________ Child’s date of birth __________ Male Female Child’s place of birth (city, county, state) ________________________ a. Date of conception (month, date, year) ______________ City, county, state where conception occurred: ___________________ b. Full term pregnancy? Yes No If no, explain: ___________________________________________________________ c. The child was conceived as a result of sexual intercourse between ______________________and me during the time stated above. d. A man is named as the father on the child’s birth certificate. Yes (attach copy) No If yes, provide his name and address: _______________________________________________________________________________________________________ e. I was married at the time of this child’s birth. Yes No If yes, complete the following: Husband’s name (first, middle, last) and last known address: ________________________________________________ _________________________________________________________________________________________________ State why husband is not the father of this child and attach all appropriate documents, including divorce decree, test results, and prior findings of non paternity, if any: ________________________________________________________________ _________________________________________________________________________________________________ f. Genetic tests were completed to determine the father of the child. Yes No If yes, attach results, explain outcome, and list name(s) and address(es) of the man or men tested: ___________________________________________________________ _______________________________________________________________________________________________________ g. I had sexual intercourse with another man or men (other than the man I am naming as the child’s natural father) during the time 30 days before or 30 days after the child was conceived Yes No If yes, complete the following: Name and address of other man/men: ___________________________________________________________________ The other man/men are biologically related to the man I am naming as the child’s natural father. Yes No If yes, state the biological relationship (e.g., brother, cousin, uncle, etc.) _______________________________________________ I do not believe the other man/men is/are the father because ____________________________________________________ ____________________________________________________________________________________________________ All the information and facts contained in this Paternity Witness Statement are true and correct to the best of my knowledge and belief. I agree to submit myself and my child, if I am the custodian, to genetic testing when necessary to establish paternity. Signature of mother _____________________________________ Date ____________________ Statement of witness to mother’s signature I willingly state that I know _________________________, who signed this form, and I witnessed her signature above. Signature of witness __________________________________ Date _________________________________________ Printed name of witness ________________________________ Telephone number of witness _______________________ Address of witness _______________________________________________________________________________________ 1604D (CSSD 04-1017 Rev. 04/27/10) (12 pp.) Custodian’s Application for Services Page 12 of 12 American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com