CS-ES50i R. 06/10 Child Support Enforcement Application Instructions Thank you for applying for child support services. Our services are free. To get started, please fill in the forms and mail or hand deliver them to us at the child support office in your county. If you live outside of Florida and • You have a Florida court order, send your application to the child support office in the Florida County of the order • You do not have a Florida court order, send your application to the child support office for the Florida County where the other parent is living • You do not know where the other parent is living, send your application to the state program office at: Florida Department of Revenue, Child Support Program, P.O. Box 8030, Tallahassee, FL 32314-8030 A list of the child support offices for each Florida County can be found at: http://dor.myflorida.com/dor/childsupport/phone.html We will open your case when we get the signed application and all the information we need. We can’t start until we get information from you. It is very important that we get all the documents and information you can provide. We need • A signed Application for Services • A separate Parent Information form for each parent. Give us as much information as you can about the other parent(s) • A separate Information About the Child form for each child. Give us as much information as you can about the child(ren) who need services • Copies of any documents you have about: o Paternity establishment. We need copies of any court judgments, the child(ren)’s birth certificates and anything the other parent signed related to the paternity of the child(ren) o Child support. If a court or another agency has ordered the other parent to pay support, we need a copy of the order and payment record(s) You may need to contact other people or the clerk of court to get the information. Once we start it is very important that you tell us right away about any changes in your • Address • Employment • The other parent’s address or employment Paper Application Instructions • Read all the forms carefully. • Pick which service you want. You can have either full services or location only services. • Give us all the information you have about the other parent. • We need a separate form for each parent. If there is more than one possible father, or a legal father and a biological father we need information about each one. • Sign all forms. If you forget, we will return the forms and will be unable to help you. • Please be sure to send us copies of the documents we need along with the application. Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com CS-ES50i R. 06/10 We need all the information you can give us. Please do your best to give us the following information: • Full names for you, the other parent and the child(ren). • Dates of birth for you, the other parent and the child(ren). • Social security numbers for you, the other parent and the child(ren). We keep the information safe. We use it only to identify individuals and to locate and collect from the other parent. • Addresses for you and the other parent. • Sex/race for you, the other parent and the child(ren). • Employer for you and the other parent. • Any other names used by you or the other parent. • Phone numbers for you and the other parent. We need copies of • The child(ren) birth certificate if the child(ren) was born in another state. • Any paternity judgments, support orders, payment records or written agreements between you and the other parent. If you don’t have copies, we need to know the county, the state and the approximate date of the order(s). If you have questions, need more forms or help filling out the forms • Call 1-305-530-2600 if your case will be handled in Miami-Dade County • Call 1-941-741-4039 if your case will be handled in Manatee County • Call 1-800-622-KIDS (5437) Services Provided and Other Information We provide services to: • Find the other parent • Find out who the legal father is • Get an order for child support • Get an order for medical support such as health insurance • Enforce medical and support orders • Change support orders • Collect and send child support payments We do not enforce visitation or custody. For more information about the Child Support Enforcement Program, go to our web site: http://dor.myflorida.com/dor/childsupport/ We will ask you to cooperate with us Cooperation means: • Giving us information and documents about you, the other parent and the child(ren). • Appearing at scheduled appointments for office visits, court or administrative hearings, or genetic testing. • Letting us know when information about you, the other parent or the child(ren) changes. • Submitting voluntarily to jurisdiction in Florida. • Giving us information we need to review and make a change in the support amount if needed. • Letting us know when you want to close your case. Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com CS-ES50i R. 06/10 Protecting your Information We have procedures and safeguards in place to protect your personal information. We use the information only for child support purposes. If you need additional protection, we can help. • Nondisclosure – You can ask us to keep your address and other personal information from appearing on notices we send. You must sign a form and provide us with additional information to have your address information protected. • Court Orders for Protection - If you have a court order for protection, give us a copy. We will not include your address on our forms or share your information. • Office of the Attorney General's Address Confidentiality Program – If you are participating in the Attorney General's Office address protection program we need a copy of your program identification card. You must also sign a form so we do not share your information with child support agencies in other states. For more information about this program contact the Office of the Attorney General in your area. Support Payments • Federal and state laws require the other parent to send support payments to the State Disbursement Unit (SDU). • We will send support payments to you usually within 2 business days of receipt. • Florida law requires us to send support payments to you electronically. You can choose to get your child support payments through direct deposit or debit card. If you do not make a choice you will receive a debit card. Once your case is set up you can get a form to select or change your payment option at: http://dor.myflorida.com/dor/childsupport/payment.html. If you are overpaid support for any reason, we will try to collect the overpaid amounts from you. Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com CS-ES51i R. 06/10 Child Support Enforcement APPLICATION FOR SERVICES We provide full child support services or location only services. FULL SERVICE You must: Give us all the information you have Give us copies of all the documents we need Give us a copy of the health insurance card if the child(ren) is insured 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 Understand that we may review the amount of support ordered and ask for a change in the amount Voluntarily submit to the jurisdiction of the State of Florida Cooperate with us as needed Tell us when you want to close the case We will: Find the other parent(s) 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 income information Base the support amount on the income of both parents Use the state’s guidelines to calculate the amount of support to be paid Tell you if you are not cooperating with us. We will give you a chance to help us before we close your case LOCATION ONLY SERVICES We will: You must: 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 you when we can’t find the other parent and close the case Give us all the information you have about the other parent Tell us about any new or changed information Tell us if you want your case closed 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 The attorney-client relationship is between the Department and the Department’s attorney, not between the attorney and me. If the case is closed, I must complete a new application to reopen the case. Name(s) of child(ren) Name(s) of other parent _______________________________________________________ ____________________________________________________ _______________________________________________________ ____________________________________________________ _______________________________________________________ ____________________________________________________ _______________________________________________________ ____________________________________________________ _______________________________________________________ ____________________________________________________ Print your full name Your signature ____/____/____ Date (____)________________________ Your daytime phone number You must complete all pages of this form. Social Security number disclosure is mandatory based on Title 42 United States Code sections 666(a)(13), 653a, and 654a(e), and on section 409.2577, Florida Statutes. We collect social security numbers for child support purposes. For more information go to http://dor.myflorida.com/dor/privacy.html Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Child Support Enforcement CS-ES51i R. 06/10 PLEASE PRINT RFA # Your Full Name (First, Middle, Last, Suffix): I have a fear of family violence and want my location kept confidential: You are the child(ren)’s: Mother Does the child(ren) live with you? Father Yes No Possible father Yes Relative (other than parents) No Non-relative If no, who do they live with? Sex: Date of Birth: Social Security Number: _______/________/__________ __ __ __ -__ __ -__ __ __ __ Female Male Driver’s License No.: Mailing Address: Issuing State City: Country: Home Phone (include area code): State: Zip Code: Best time to call: Work Phone (include area code): Best time to call: Cell Phone (include area code): Race: Asian Black Hispanic White Native American Other Best time to call: Other Legal Names You Are Known By: ____________________________________ ____________________________ Maiden Former married Nickname ____________________________________ ____________________________ Maiden Former married Nickname ____________________________________ ____________________________ Maiden Former married Nickname ____________________________________ ____________________________ Maiden Former married Nickname Answer employment questions only if you are the mother or the father Employer: Employer’s Address: Employer’s City: Is health care coverage available through this employer? Employer’s State: Yes No Employer’s Zip: Unknown Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Child Support Enforcement CS-ES51i R. 06/10 Parent Information Parent not in the home A separate Parent Information form (CS-ES52) is required for each parent not living in your home with the child(ren). Other Parent’s Full Name (First, Middle, Last, Suffix): Are you seeking child support from this Social Security Number: parent? Date of Birth: Sex: __ __ __ -__ __ -__ __ __ __ Female Male Home Phone (include area code): Current City: State: Last Known Mailing Zip code: Residential Driver’s License No.: Employer: No ______/______/________ Cell Phone (include area code): Work Phone (include area code): Address: Yes Country: Issuing State: Employer’s Address: Employer’s City: Employer’s State: Employer’s Zip: Is health care available from this employer? Yes No Unknown Place of Birth (City/County/State/Country): Other Names Known By: ____________________________________ ____________________________ Alias Nickname ____________________________________ ____________________________ Alias Nickname Weight: Race: Height: Asian Black Hair Color: Eye Color: Hispanic White Other Identifying Features: None Piercings Gold Teeth Scars Mustache Beard Glasses Tattoos Pigtails Ponytail Bald Other: __________________________________________________ Native American Other List this parent’s children (or possible children) included in this application. Please complete an additional Child Information form (CS-ES51ACI) for each child listed. Child’s Full Name (First, Middle, Last, Suffix) Child’s This Parent’s Relationship to the Child Social Security Number (Mother, Father or Possible Father) _________________________________________________________ ___________________ _____________________________ _________________________________________________________ ___________________ _____________________________ _________________________________________________________ ___________________ _____________________________ _________________________________________________________ ___________________ _____________________________ _________________________________________________________ ___________________ _____________________________ _________________________________________________________ ___________________ _____________________________ _________________________________________________________ ___________________ _____________________________ _________________________________________________________ ___________________ _____________________________ _________________________________________________________ ___________________ _____________________________ Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Child Support Enforcement CS-ES51i R. 06/10 Information about the Child Child’s Full Name (First, Middle, Last, Suffix): Child’s Social Security Number : Child’s Sex: Female Male Child’s Date of Birth:____/____/_____ Child’s Race: Asian Black Hispanic White Child’s Place of birth (City/ County /State/Country): Is the father’s name on the birth certificate? __ __ __ -__ __ -__ __ __ __ Native American Yes No Unknown Date child began living with you: : ____/____/_____ Is this child disabled? Yes No Other Birth Certificate No. _______________________________ Print father’s name listed on the birth certificate: _______________________________________________________________________ Has this child ever lived with the other parent in Florida? Yes No Unknown If yes, provide the approximate dates: Print the other parent’s name: _______________________________________________ From ______/______/________ to ______/______/________ City in Florida where they lived together? _________________________ Is there a support order for this child? Yes No Medical Only Unknown If yes, print the name of the person who is ordered to provide support: ______________________________________________________ Date of order: ______/______/________ Court Case number: _______________________________________________________ County/state/country where order was entered: ________________________________________________________________________ Where is support paid? Clerk of Court Is this child covered by medical insurance? Yes State Disbursement Unit No Medicaid Paid directly to me Unknown Provided by: Mother Father Medicaid Step-parent relative Other: _________________________________________ Is any legal action pending with the other parent regarding this child? Yes No Unknown Print the other parent’s name: _____________________________________________________________________________________ If yes, attorney’s name, address and phone #: If Yes: Type of Action: Custody Adoption Mediation Enforcement Modification Other: ______________________ IF THIS CHILD IS INCLUDED IN A SUPPORT ORDER DO NOT COMPLETE THE REMAINING QUESTIONS FOR THIS CHILD Does this child have other possible fathers? Yes No Unknown If yes, list name(s) of other possible fathers of this child: Approximate date the mother became pregnant with this child: ______/______/______ Where the mother became pregnant: (City/County/State/Country): Full Term? Yes No Unknown ______________________________________________________________________________________________________________ Was the mother married to anyone when she became pregnant with this child? Yes No Unknown Was the mother married to anyone when this child was born? Yes No Unknown If yes, date of marriage: ____/______/_____ Married to whom: __________________________________________________ Married where (City/ County /State/Country): __________________________________________________________________________ Was the mother divorced from the man named above? Yes No Unknown If yes, date of divorce: ____/______/_____ Court Case #: _____________________ Divorced where (City/ County /State or Country): _____________________________________ Has the other parent provided any type of support for this child? Yes No Unknown Print the other parent’s name who provided support: ___________________________________________________________________ If yes, type: Money Diapers Milk Shelter Social Security Amount: _________________ Other: _______________________ Paid for Daycare: Yes No If yes, amount ___________and how often _____________ Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com