CSSD 04-1017B (Rev. 10/30/18) (10 pp.) Noncustodian222s Application for Services Page 1 of 10 STATE OF ALASKA DEPARTMENT OF REVENUE CHILD SUPPORT SERVICES DIVISION NONCUSTODIAL PARENT222S 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 Court222s child support rule, Civil Rule 90.3. The application and the 223Statement of Support Provided224 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 223Affidavit and Request for Address Confidentiality224 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 226 Main Office Fairbanks 550 W 7th Ave Suite 310 675 7th Ave Station J2 Anchorage AK 99501-6699 Fairbanks AK 99701-4531 (907) 269-6900 (907) 451-2830 Mailing address for payments CSSD PO Box 100380 Anchorage AK 99510- 0380 American LegalNet, Inc. www.FormsWorkFlow.com CSSD 04-1017B (Rev. 10/30/18) (10 pp.) Noncustodian222s Application for Services Page 2 of 10 NONCUSTODIAN222S 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 Paternity only establishment Medical support order establishment Enforcement of an existing order Review, modification, and enforcement of an existing order Full name Birth or previous names used Birthdate Birthplace SSN Driver222s license state and # Mailing address City State Zip Residence address City State Zip Home phone Work phone Email address OccupationEmployer Work hours Does an attorney represent you in any matters related to the child or the custodian? Yes No If yes, provide the attorney222s 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 Child222s full name Sex Date and place of birth Social security # Who does this child live with? You are the mother father relative other (explain) . Full name Birth or previous names used Birthdate Birthplace SSN Driver222s 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? INFORMATION ABOUT YOU (THE NONCUSTODIAN APPLICANT) PLEASE PRINT CHILDREN FOR WHOM YOU ARE REQUESTING SE RVICES ABOUT THE OTHER PARENT (THE PERSON WITH CUSTODY) For office use only: Requested: Sent: Case #: Date Date Reinstatement/Existing/Other American LegalNet, Inc. www.FormsWorkFlow.com CSSD 04-1017B (Rev. 10/30/18) (10 pp.) Noncustodian222s Application for Services Page 3 of 10 Height Weight Hair color Eye color Race Marks, scars, tattoos EmployerWork 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 Tribal or Alaska Native corporation member? Yes No If yes, which corporation? Does the custodian have an attorney regarding child support? 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 Divorced Date City/state Case number Attach a complete copy of the divorce decree or order. 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. Child: Did the father sign an Affidavit of Paternity? Yes No Is the father222s 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 father222s name on the birth certificate? Yes No In what state was the birth certificate issued? Other (explain) 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 223Affidavit and Request for Address Confidentiality.224 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 Anchorage AK 99501-6699 RELATIONSHIP BETWEEN THE CUSTODIAN (THE OTHER PARENT) AND YOU OTHER INFORMATION American LegalNet, Inc. www.FormsWorkFlow.com CSSD 04-1017B (Rev. 10/30/18) (10 pp.) Noncustodian222s Application for Services Page 4 of 10 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 op