CS-ES51 INet R. 9/07 Child Support Enforcement APPLICATION FOR SERVICES We provide full child support services or location only services. FULL SERVICE You must: We will: • Give us all the information you have • Give us copies of all the documents we need • Tell us of any changes in information for you, the child(ren) or other parent(s). This includes addresses, employment, phone numbers, and where the child(ren) lives • Keep all appointments with us • Go to all court or administrative hearings. Use the state’s guidelines to calculate the amount of support to be paid • Understand that we may review the amount of support ordered and ask for a change in the amount Tell you if you are not cooperating with us. We will give you a chance to help us before we close your case. • Voluntarily submit to the jurisdiction of the State of Florida • Cooperate with us as needed • Tell us when you want to close the case Find the other parent Get paternity established Get an order for child support or medical support Send you payments we collect Review and change the amount of support ordered Review available information we have to be sure the support amount is based on the income of both parents LOCATION ONLY SERVICES You must: • Give us all the information you have about the other parent. We will: • Use the sources we have to find the other parent. • Tell you when we find the other parent’s address or employer and close the case. • Tell us about any new or changed information • Tell us if you want your case closed Tell you when we can’t find the other parent and close the case. _________________________________________________________________________________________________ • I WANT TO APPLY FOR THE FOLLOWING SERVICES FOR THE CHILD(REN) NAMED BELOW AND AGREE TO COOPERATE fully with the Department (check one): full child support enforcement services location only services I UNDERSTAND • That the attorney-client relationship is between the Department and the Department’s attorney, not between the attorney and myself. • If the case is closed, I need to complete a new application to reopen the case. ____________________________________ ___________________________________________________ Name(s) of child(ren) Name of other parent ____________________________________________ Print your full name ______________________________________ Your signature ____/____/____ Date (____) ______________ Your Daytime Phone Number __________________ Your E-mail Address You also must complete the second page of this form. Your Social Security number and the child(ren)’s are required by section 409.2567, Florida Statutes and Rule 12E-1.003(2)(a), Florida Administrative Code. We will use the numbers only for purposes directly connected with child support enforcement. American LegalNet, Inc. www.FormsWorkflow.com CS-ES51 R. 9/07 #: To be completed by CSE NA 1. Information about you Does the child live with you? You are the child’s: Custodial Parent Noncustodial Parent PLEASE PRINT Yes mother Applicant is: PA No If no, who do they live with? father grandparent legal guardian If you are not the parent, Mother give the names of the children’s parents: Name (First, Middle, Last): other, specify _______________________________ Father How long have the child(ren) lived with you? Social Security Number: Race Sex Mailing Address: Date of Birth: City: Home Phone (include area code): Best time to call: State/Zip Code: Work Phone (include area code): Best time to call: Was the mother married when the child was born? Where (City/State)? ___________________ Divorced? Yes No If yes, to whom? Yes When? __________________ Yes Yes No No A separate form is required for each parent not living in your home Name (First, Middle, Last): Home Phone (include area code): Current Address: Work Phone (include area code): Last Known Mailing Residential (check all that apply) Dates other parent lived with you and the child(ren) From: ___________ To: ____ _________ Where? (City/State):__________________________ Employer: City: State/Zip Code: Social Security Number: Date of Birth: Employer’s Address: Place of Birth: Race: _______________________ No If yes, Date: ____________ Any other legal action pending?: I have a fear of family violence and want my location kept confidential: 2. Information about the other parent Other Legal Names Used: Employer’s City: Sex: Weight: Height: Hair: Eyes: Employer’s State/Zip Code: Other Identifying Features: 3. Child(ren) Who Need Services Child’s Name/sex Social Security Number Child #1 __________________________ M F Child #2 __________________________ M F Child #3: __________________________ M F __ __ __ -__ __ -__ __ __ __ __ __ __ -__ __ -__ __ __ __ __ __ __ -__ __ -__ __ __ __ ______/______/______ ______/______/______ ______/______/______ Place of Conception (City/State) Place of Birth (City/State) Date of Birth (MM/DD/YY) Were the parents married Yes No Yes No Yes No when the child was born? Did the father sign the birth Yes No Yes No Yes No certificate? If other possible fathers, list name(s) and complete another form: Is there a support order for Yes No Medical Only Yes No Medical Only Yes No Medical Only this child? Covered by other parent’s Yes No Yes No Yes No medical insurance? Please include copies of any paternity, divorce, or child support orders you have for the child(ren). If there are orders but you do not have copies, please give us the information so we can get them. County and state where order was entered: Approximate date: Case number, if known: Please check one of the boxes below to show where the other parent is ordered to make child support payments: Child support payments are made to the Clerk of Court Child support payments are paid directly to me If you need help, call Customer Contact Center at 1-800-622-5437 or go to http://www.myflorida.com/dor/childsupport Your Social Security number and the child(ren)’s are required by section 409.2567, Florida Statutes and Rule 12E-1.003(2)(a), Florida Administrative Code. We will use the numbers only for purposes directly connected with child support enforcement. American LegalNet, Inc. www.FormsWorkflow.com