STATEMENT OF SUPPORT RECEIVED See instructions on the next page. If you received no support, please submit this statement with the "no support received" options checked in Items 4 and 5. 1. Your name ____________________ CSSD Case # ____________ Noncustodial 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 all the appropriate boxes in items 3-6, and complete the table below (or submit separate pages if necessary). An administrative order from A court order directs that you are No administrative or court 3. OR CSSD or another child support entitled to receive order for child support is in OR child support agency directs that you are effect at this time. alimony (spousal support) entitled to receive child support. 4. List in the table below the child support payments you have received directly from the noncustodial parent. Don't forget to indicate the year(s). If you aren't sure how much child support you've received from the noncustodial 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 noncustodial parent, list your best estimate by month and year in the table below (or on a separate page). You have received no child support from the noncustodial parent. OR OR 5. List in the table below the alimony (spousal support) you have directly from the noncustodial parent. Don't forget to indicate the year(s). OR OR You have received no alimony (spousal support) from the noncustodial 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 children) at any time since the order was issued? time periods when you lived together (or when the other parent had custody) since the child support order was issued. Year: Child Support Alimony/ Spousal Year: Child Support Alimony/ Spousal Year: Child Support Alimony/ Spousal Jan Feb Mar Apr May Jun July Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun July Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun July Aug Sep Oct Nov Dec Signature ______________________________________________ CSSD main office mailing address: 550 W 7th Ave Suite 310 Anchorage AK 99501-6699 [ CSSD 04-1606b (Rev. 01/13/04) (2 p.) Statement of Support Received (3 yr version) Date _______________________ Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Completing the Statement of Support Received 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 noncustodial parent. 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 noncustodial 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 support during more than three years, copy the first page or ask CSSD for the long version of this statement. 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 (mark them as "estimates"). Or you may submit estimates 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 noncustodial parent's disability or retirement, these benefits may be credited toward the noncustodial 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 noncustodial 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 support during more than three years, copy the first page or ask CSSD for the long version of this statement. 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 (mark them as "estimates"). Or you may submit estimates 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: Start with the first month and year you were supposed to receive support, and continue through the current month and year. Add additional pages, if necessary. Enter "0" in months when no support was received. 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 Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Child Support Alimony/ Spousal Year 2001 Jan Feb Mar Apr May Child Support Alimony/ Spousal N/A N/A $0 $75 $50 $0 $0 $75 $175 0 0 $200 $100 $0 N/A $100 0 $150 $150 0 $225 $175 Jun Jul Aug Sep Oct Nov Dec [ CSSD 04-1606b (Rev. 01/13/04) (2 p.) Statement of Support Received (3 yr version) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com