DR-17 (4/01) DR or DM Case No.:APPLICATION FOR CHILD SUPPORT (IVD) SERVICES (NON ADC RECIPIENT)Certification Mandated by R.C. 3125.36 Name of Custodial ParentName of Non Custodial Parent AddressAddressSS No.: SS No.: Telephone No.Names of child(ren) & SS No. (if available): (Custodial Parent) SEA No.: (if assigned)This request is for the purpose of securing support for my minor children and for no other purpose. This application can be revoked by me at any time by means of written notice. I understand that I must notify the Montgomery County Human Services Department, Support Enforcement Agency, of any change in the information listed on this form. I hereby request the following child support services: Full service which includes location and/or the following: -Establishment of Paternity -Establishment of Court Order -Enforcement of Court Order -Modification of Court Order -Collection and disbursement of support The designated administrative agency for the Child Support (IVD) program in Montgomery County is the Human Services Department. Should you have any questions or concern regarding service, please contact Montgomery County Human Services Department, Support Enforcement Agency.for agency only IV-D Representative Date:Signature of Parent/Legal Guardian Date:ODHS 7076 (Rev 5/90)2002 © American LegalNet, Inc.