FOR OFFICIAL USE ONLY DATE STAMP DATE APPLICATION REQUESTED DATE APPLICATION PROVIDED DATE APPLICATION RECEIVED DIVISION OF WELFARE AND SUPPORTIVE SERVICES APPLICATION FOR CHILD SUPPORT SERVICES CASE NUMBER: PLEASE CAREFULLY READ THE FOLLOWING INFORMATION. Child Support Enforcement (CSE) Program Services: Locate all noncustodial parents and/or sources of income and/or assets;Enforce financial and medical support;Establish paternity (determine who is the father of the child(ren));Review and adjust existing child support orders;Establish financial and medical support; The CSE program: must provide all the above services to all individuals, unless the individual is a Medicaid recipient and the Medicaid recipient notifies the CSE program in writing they only want medical support services; has sole discretion in determining which legal remedies are used to provide the above services and cannot guarantee success; may request assistance of another state and, thereby, be subject to the laws of that state. It may take ninety (90)days, or more, after the other state receives the request for services before any information is available; does not provide services involving custody, visitation or unpaid medical bills. However, these services may be available through a private attorney; will close your cases upon written request from you or when your case meets closure rules established by federal and state regulation. Important Information You Should Know: The CSE program: will impose a $25 annual fee in each case where an individual has never received TANF cash assistance and for whom the State has collected at least $500 of child support. represents the State of Nevada when providing services and no attorney-client privilege exists; is authorized to endorse and cash checks, money orders and/or other forms of payment made payable to you for support payments; child support payments will be made as a direct deposit into your bank account, or by a Nevada Debit Card. A Nevada Debit Card will be issued to you unless you request payments by direct deposit. For more information regarding direct deposit, please call toll free to the Child Support Customer Service Unit at (800)992-0900 or check the Child Support Enforcement State Collections and Disbursement Unit (SCaDU)website at to print a Direct Deposit AuthorizationAgreement. may collect past-due support by intercepting an IRS tax refund or other federal payment. If a tax intercept occurs, the CSE program has the authority to hold a joint tax refund for a period of six (6) months before distributing the funds. No interest is paid on the held funds. Funds collected from tax intercept are applied first to pay off any past-due support assigned to the State of Nevada. A nonrefundable fee is deducted by the federal government for any tax or federal payments intercepted by the CSE program. By accepting cash or medical assistance for yourself or the child in your custody, you have made an assignment to the Division of Welfare and Supportive Services of all rights to support from any person. Any unpaid support assigned to the State of Nevada may be enforced and collected until paid in full. (Page 1 of 7) 4000 EC (7/15) American LegalNet, Inc. www.FormsWorkFlow.com If you receive cash assistance, support payments are kept by the State of Nevada to pay off any past-due support assigned to the state. When you are off cash assistance, support payments are sent to you until you request case closure in writing. However, any unpaid support assigned to the State of Nevada may be enforced and collected until paid in full. All support payments are sent to and processed by the CSE program and distributed according to federal and state regulations. The CSE program is required by Chapter 42 of the United States Codes, federal regulations, and state laws that established the CSE program to obtain the social security numbers (SSN) for those individuals receiving child support services. The SSN is needed to properly establish and enforce child support obligations based on program services and comply with reporting requirements contained in the federal and state laws and regulations previously mentioned. Any individual who fails to disclose this information may result in the denial of child support services. The CSE program will use these SSNs only for the purpose of providing services outlined in the federal law, federal regulations, state laws, and state regulations that govern the CSE program. In accordance with federal law and U.S. Department of Health and Human Services (HHS) policy, the Division of Welfare and Supportive Services is prohibited from discriminating on the basis of race, color, national origin, sex, age or disability. To file a complaint of discrimination, write HHS, Director, Office for Civil Rights, Room 506-F, 200 Independence Avenue, S.W., Washington, D.C. 20201 or call () - (voice) or () - (TDD).Responsibilities: You are responsible for: providing all available information requested by the CSE program. This may include certified copies of a of the noncustodial parent; participating in genetic testing to establish paternity. If the genetic test proves the person named is not the father, you may be required to pay the cost of the genetic test; reporting when any of the following changes happen; 1.Name change, new address or telephonenumber for home or work;2.A private attorney or collection agency ishired;3.Another child support or paternity legalaction is filed;4.Filing for divorce;5.Receive support payments directly fromthe noncustodial parent;6.New address, telephone number, employ-ment or health insurance for the noncustodialparent;7.Child(ren) no longer live with you;8.Child(ren) still in high school after age 18;9.Child(ren) become disabled before age 18;10.Child(ren) come to live with you or birth ofanother child;11.A child marries, is adopted, joins the armedforces or is declared an adult by court order. requesting a review and adjustment of the existing support order once every three years or if there is a significant change in circumstances; turning in support payments you receive directly from the noncustodial parent when you are receiving cash assistance; repayment of support amounts received in error, including support payments from an IRS tax refund which are adjusted by the IRS. If you fail to enter into a repayment agreement with the CSE program, the outstanding balance may be reported to a credit reporting agency and money collected on your behalf by the CSE program may be withheld for repayment. Additionally, legal action may be initiated against you. Application Instructions: You must answer all questions. Please PRINT OR TYPE answers in black or blue ink. Check Yes, No, Unknown or write N/A (not applicable) in any space which does not apply. Use a separate sheet of paper if you need more room for any answer or if you have additional information regarding the noncustodial parent which is not covered by the questions on this form. (Attach copies of all support court orders.) The application must be signed on pages 6 and 7. Services could be delayed if your application is not complete and signed. (Page 2 of 7) 4000 EC (7/15) American LegalNet, Inc. www.FormsWorkFlow.com COMPLETE THE FOLLOWING ABOUT YOU, THE CUSTODIAN (CST), OF THE CHILD(REN): Name ( Last, First, Middle) Other Last Names Used Resident Address (City, County , State & Zip Code) How long lived in Nevada? Mailing Address (If different than above) Home Phone No. ( ) Work Phone No. ( ) Cell Phone No. ( ) E - Mail Address: Social Security No. Birth Date Birth Place Mal e Female Height ft in Weight lbs Hair Color: Eye Color: Race: Employer Name & Address (City, State, & Zip Code) Job Title Are you: Single Married Divorced Living with a boyfriend or girlfriend What is your relationship to the children? (Mother, father, grandparent, etc.) Date children began living with you (month/year)? MEDICAL/HEALTH INSURANCE INFORMATION: Do you and the children have satisfactory medical/health insurance (not Medicaid)? Yes No Monthly cost? Is medical/health insurance available with your employer? Yes No Monthly cost? Please attach a copy of your