IL Dept of Healthcare and Family Services APPLICATION FOR CHILD SUPPORT ENFORCEMENT SERVICES (TITLE IV-D) Division of Child Support Enforcement Mail Response Unit P.O. Box 19405 Springfield, IL 62794-9405 DATE: NAME: ADDRESS: SEX: SSN: DATE OF BIRTH: DAYTIME PHONE NO: WORK PHONE NO: Este es un aviso muy importante. Si usted no entiende este aviso, comuníquese con el Centro de Servicio al Consumidor en la Sección de Manutención de Niños a 1-800-447-4278, dónde le podrán explicar este aviso. Personas que usan teletipo (TTY) deben llamar a 1-800-526-5812. This is an important notice. If you do not understand this notice, contact the Child Support Customer Service Call Center at 1-800-447-4278 who can explain it to you. Persons with a TTY device may call 1-800-526-5812. So that we can provide the best and quickest services possible, please: • • • • Complete this form. Please print or type. Any information that you do not know, please write “don’t know” in the blank. Read the enclosed Non-Assistance Program Fact Sheet. It explains the services we provide. Mail this form and copies of any order(s) you already have to the address listed above. If you are NOT the biological or legal parent of the child, complete the application available at www.ilchildsupport.com or call 1-800-447-4278 for a different application. If you are working with an attorney on your child support needs, signing up for HFS child support services could provide additional services to you and your family. You can work with your attorney and HFS at the same time. Applicant’s Information: Full Name: (first) (middle initial) (last) Home Address: (Street) (City) (County) (State) (Zip) Relationship to Child: Date of Birth: Age: SSN: Race: (mm/dd/yyyy) Home Telephone #: Work Telephone #: Cell Telephone #: E-Mail Address: What time of day is most convenient to talk to you? CP: HFS 1283 (R-8-09) At what telephone number? NCP: IV-D# IL478-0028 American LegalNet, Inc. www.FormsWorkFlow.com Other Parent’s Information: Full Name: (first) (middle initial) (last) Home Address: (Street) (City) (State) (Zip) Relationship to Child: Date of Birth and/or Age: Home Telephone #: SSN: Race: Work Telephone #: ____ Cell Telephone #: E-Mail Address: Name of Employer or Source of Income: Employer’s Address: Is the other parent of the child in the military? Yes ___ No __ Which branch of service? Make and Model of Car: (Send us a copy of military insurance card, if available) License Plate #: Other Parent’s Relatives: (mother) ___________ __________ (father) Does the other parent have additional children with someone else? If you know the other children’s names, list them here. Child’s Information: Full Name: Sex: (first) Date of Birth: (middle initial) (last) Place of Birth: mm/dd/yyyy city Social Security Number: state Race: If you have any additional children with this parent, please provide the same information on a separate sheet of paper. CP: HFS 1283 (R-8-09) NCP: IV-D# IL478-0028 American LegalNet, Inc. www.FormsWorkFlow.com Other Important Information 1. Are/were you married to the other parent of the child? Yes 2. Are you and the other parent of the child divorced? Yes State of Divorce Order: If yes, what date? No If yes, what date? County of Divorce Order: No Order Docket Number: 3. If you already have a child support order for the child, it is important that you send us a copy of the order with this application, if available. Order or Docket # Where was the order entered? (City) (County) (State) When did the order start? (month/year) You may request that an amount be included in your order to cover support for a period prior to the date your child support order is first established. I authorize the Division of Child Support Enforcement to explore, pursue or utilize all sources of information legally available in support of its investigations on my behalf and to choose the appropriate course of legal action. I have received and read the program fact sheet provided with this application. To the best of my knowledge, the information I have supplied is true, correct, and complete. I understand the Division will protect my privacy as required by law, and I authorize the Division to disclose information about my case to the court or another party necessary in the course of establishing and enforcing paternity and child support orders, for as long as I am a client. All information you provide is kept confidential but we understand that domestic violence may also be an issue for you and your family. For your protection, we can mark your case with a family violence indicator. If you would like us to place this indicator on your case, check the box below. If this is not an issue for your family, you do not need to check the box.  Yes, I want my case marked with a family violence indicator. Applicant’s Signature (required) CP: HFS 1283 (R-8-09) NCP: Date IV-D# IL478-0028 American LegalNet, Inc. www.FormsWorkFlow.com