County Reproduced JFS07076 (9/2001) Page 1 of 5 LAKE COUNTY CHILD SUPPORT ENFORCEMENT 177 MAIN STREET PAINESVILLE, OHIO 44077-9967 Date: Application #: APPLICATION FOR CHILD SUPPORT SERVICES NON-PUBLIC ASSISTANCE APPLICANT/RECIPIENT IMPORTANT: If you are receiving OWF or Medicaid, do not complete this application, because you became eligible for child support services when you signed the OWF/Medicaid application. I, , request child support services from the LAKE County Child Support Enforcement Agency. I understand and agree to the following conditions: A. I am a resident of the county in which services are requested and no other Ohio county has jurisdiction over support - OR - I am requesting services from the Ohio county of jurisdiction. B. Recipients of child support services shall cooperate to the best of their ability with the CSEA. (See attached rights and responsibility information.) The Child Support Enforcement Agency can assist you in providing the following services: 1. Location of Absent Parents. The agency can assist in finding where an absent parent is currently living, in what city, town or state. The applicant can request location only services, if the sole need is to find the whereabouts of the absent parent. 2. Establishment or Modification of Child Support and Medical Support. The CSEA can assist you in obtaining an order for support if you are separated, have been deserted or need to establish paternity (fatherhood). The CSEA can also assist you in changing the amount of support orders (modification), and to establish a medical support order. 3. Enforcement of Existing Orders. The CSEA can help you collect current and back child support. 4. Federal and State Income Tax Refund Offset Submittals for the Collection of Child Support Arrearages. The agency can collect back support (arrearages) by intercepting an obligors federal and state income tax refunds on some cases. American LegalNet, Inc. www.USCourtForms.com>>>> 2County Reproduced JFS07076 (9/2001) Page 2 of 5 5. Withholding of wages and Unearned Income for the Payment of Court Ordered Support. The agency can help you get payroll deductions for current and back child support and can intercept unemployment compensation to collect child support. 6. Establishment of Paternity. The agency can obtain an order for the establishment of paternity (Fatherhood), if you were not married to the father of the child. An absent parent may request paternity services in Ohio until the child has reached the age of 23. 7. Collection and Disbursement of Payments The CSEA can collect the child support for you, and send you a check for the amount of the payments received. Back support collected will be paid to you until all of the back support you are owed is paid. 8. Interstate Collection of Child Support. The agency can assist you in collecting support if the payor is living in another state or in some foreign countries. APPLICANT INFORMATION Name: Date of Birth: Home Address: Mailing Address: ___________________________ __________________________ Home Phone: Sex: SSN: Race: Current Marital Status: Relationship G Divorced G Separated to children: G SingleG Married Military Ever been on Public Assistance? Service (Branch, Dates) When? Which State? EMPLOYER INFORMATION Employer Name: Employer Phone: Employer Is Medical Insurance Available? Address: ___________________________ American LegalNet, Inc. www.USCourtForms.com>>>> 3County Reproduced JFS07076 (9/2001) Page 3 of 5 INFORMATION ON CHILDREN CHILD 1 CHILD 2 CHILD 3 Name: Sex: Race: Social Security #: Date of Birth Home Address Street Address City, State, Zip Location of Birth: (County, City, State, Country) Has Paternity (fatherhood) been established? Is there an order for support? Is the child covered by Medical Insurance? ABSENT PARENT INFORMATION PARENT 1 PARENT 2 PARENT 3 Name (and alias): Alias: Alias: Alias: Home Address: Street Address City, State, Zip Mailing Address: Street or P.O. Box City, State, Zip Social Security #: Date of Birth: Location of Birth: (County, City, State, Country) Race: Sex: Height/Weight: American LegalNet, Inc. www.USCourtForms.com>>>> 4County Reproduced JFS07076 (9/2001) Page 4 of 5 PARENT 1 PARENT 2 PARENT 3 Hair/Eye Color: Identifying Marks: (Tattoos, scars, etc.) Name and Address of Employer Street Address City, State, Zip Wage Earnings: Employer Phone #: Is Medical Insurance Provided? Support Order #: Date of Support Order: Amount of Support: Order Frequency: Location Where Order was Issued: Military Service (Branch, Dates) Ever Incarcerated? (Location, Dates): Currently Institutionalized? If yes, where? Arrest Record (Location, Dates): Name of Current Spouse Address (Street) City, State, Zip A.P. Fathers Name: A.P. Mothers Name (Maiden): Has AP Ever been on Public Assistance? (Location, Dates) American LegalNet, Inc. www.USCourtForms.com>>>> 5County Reproduced JFS07076 (9/2001) Page 5 of 5 Type (s) of Service(s) Requested: GAll Services Listed. GLocation of Absent Parent Only GOther (please explain): ____________________________________________________________ I understand that the child support agency within 20 days of receiving this application will contact me by awritten notice to inform me if my case has been accepted for child support services (IV-D Services). Signature of Applicant: Date: American LegalNet, Inc. www.USCourtForms.com>>>> 6 JFS 04059 (9/2001)County Reproduced Page 1 of 3 Explanation of State Hearing Procedures WHAT IS A STATE HEARING? If you think there has been a mistake or delay on your case, you may want to ask for a state hearing. You can ask for a hearing about actions by either the State Department of Job and Family Services or the local agency. Local agencies include the County Department of Job and Family Services (CDJFS), the County Child Support Enforcement Agency (CSEA), and agencies under contract with them. A state hearing is a meeting with someone from the local agency, and a hearing officer from the Ohio Department of Job and Family Services (ODJFS). The local agency will explain the action it has taken or wants to take on your case. Then you will have a chance to tell why you think it is wrong. The hearing officer will listen to you and to the local agency, and may ask questions to help bring out all the facts. The hearing officer will review the facts presented at the he