STATE OF INDIANA COUNTY OF ELKHART ) )SS: ) TITLE IV-D NOTICE AND WAIVER I, the undersigned custodial parent or custodian, hereby acknowledge that the Prosecuting Attorney is an agent of the State of Indiana and the Indiana Family and Social Services Administration, and cannot and does not serve as a private attorney to custodial parents or other custodians. The function of the Office of the Prosecuting Attorney is to protect and promote the interests of the State at large and the best interests of children in particular, and these interests may conflict at times with my interests or desires. I understand that the Prosecuting Attorney does not actually represent custodial parents or custodians, but is merely providing child support services under Title IV-D of the Federal Social Security Act. These services are limited to: (1) location of absent parents; (2) establishment of paternity and other support orders; (3) enforcement of support orders; and (4) modification of support orders. Furthermore, I realize that the Prosecuting Attorney is not my personal attorney, and that I may need to consult with a private attorney or a legal services agency regarding my legal rights, including but not limited to dissolution, separation, paternity, custody, visitation, and property settlement. I acknowledge that I am not entering into an attorney-client relationship with any attorney in the Office of the Prosecuting Attorney, and that any confidential information provided to the Prosecutor’s Office is not information protected by and attorney-client relationship. As such…any information provided to the Office of the Prosecuting Attorney may be used by that Office in the prosecution of criminal offenses or civil violations without regard to the source of the information. I further acknowledge that involvement in the Title IV-D Child Support Program does not protect me from prosecution of any criminal offense or civil infraction. NOTE: THIS FORM IS A WAIVER OF LEGAL RIGHTS AND SHOULD BE SIGNED ONLY AFTER BEING READ CAREFULLY. YOUR SIGNATURE VERIFIES THAT YOU HAVE READ AND UNDERSTAND THE CONTENTS OF THIS DOCUMENT. I have read the above and fully understand the contents of this waiver and consent to its terms. I affirm under the penalties of perjury that foregoing representations are true. Date: Signature of Custodial Parent/Custodian American LegalNet, Inc. www.USCourtForms.com