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Application For Child Support Services Non Public Assistance Applicant Form. This is a Ohio form and can be use in Montgomery County (Court Of Common Pleas).
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Tags: Application For Child Support Services Non Public Assistance Applicant, JFS 07076, Ohio County (Court Of Common Pleas), Montgomery
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
APPLICATION FOR CHILD SUPPORT SERVICES
:
Index No.
NON-PUBLIC ASSISTANCE APPLICANT
IMPORTANT: If you are receiving ADC or Medicaid, do not complete this application, because you became eligible for child support services when you became eligible to
:
Calendar No.
receive ADC or Medicaid.
I the undersigned,
Agency. I understand and agree to the following conditions:
request Child Support Services from the :
-against-
:
Plaintiff(s)
County Child Support
JUDICIAL SUBPOENA Enforcement
A.
I am a resident of the County in which services are requested.
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.
Defendant(s)
:
The.agency can . . . . in . . . . . . . . an absent parent is currently . . . . in . . . . . . town or . .
. . . . . . . assist . finding where . . . . . . . . . . . . . . . . living, . what city, . . . . state. The applicant can request "Location Services Only", 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 to obtain an order for support if you are separated, have been deserted or need to establish paternity (fatherhood). The CSEA can also
THE in changing OF THE STATE OF NEW YORK
assist youPEOPLEthe amount of support orders (modification), and to establish a medical support order.
3.
Enforcement of Existing Orders.
TO
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 assist in collecting back support (arrearages) by intercepting a non-payor's federal and state income tax refunds on some cases.
GREETINGS:
5.
Withholding of Wages and Unearned Income for the Payment of Court Ordered Support.
6.
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
Establishment of Paternity.
located at
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and parent may request
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 at any recessed
paternity services. date, to testify and give evidence as a witness in this action on the part of the
or adjourned
7.
Collection and Disbursement of Payments.
The agency can help you get payroll deductions for current and back child support and can intercept unemployment compensation to collect child support.
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.
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
as a
result of your failure to comply.
the party on whose and support was assigned to was issued for collected will be paid to the state $50 and all damages sustained
If you received ADC in the pastbehalf this subpoenathe state, back support a maximum penalty of after you receive back support owed to you.
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.
C.
D.
Witness, Honorable
The only fee you can be charged for services is a one dollar application fee.
Court in
County,
day of
, one of the Justices of the
Some,counties pay this fee for the applicants.
20
In providing IV-D services, the CSEA and any of its contracted agents (e.g., prosecutors, attorneys, hearing officers, etc.) represent the best interest of the children of
the state of Ohio and do not represent any IV-D recipient or the IV-D recipient's personal interest.
(Attorney must sign above and type name below)
APPLICANT INFORMATION (INFORMATION ABOUT YOU)
Name
Date of Birth
Social Security Number (SSN)
Current Marital Status (Check One)
Attorney(s) for
Single
Deserted
Type(s) of Service(s) Requested: All services listed
Other (please explain)
Married
Widowed
Divorced
Separated
Office and P.O. Address
Location of absent parent only
I understand that the Child Support Agency - within 20 days of receiving this application will contact me by a written notice to inform me if my case
Telephone No.:
has been accepted for child support services (IV-D Services).
Signature of Applicant
JFS 07076 (Rev. 5/2001)
(Formerly DHS 7076)
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
Date
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COURT
Applicants Name (Last, First, Middle)
COUNTY . .
. . . . . . . . . .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
:
Address (Street/Route, P.O. Box)
Telephone Number (Home)
Index No.
(Work)
:
Calendar No.
:
City, State, Zip Code
JUDICIAL SUBPOENA
Plaintiff(s)
INFORMATION ON CHILDREN
-againstChild 1
:
Child 2
a. Name
:
c. SSN
Child 4
:
b. Sex
Child 3
Defendant(s)
:
......................................................
d. Date of Birth (DOB)
e. Name(s) of Absent Parent
THE PEOPLE OF THE STATE OF NEW YORK
f. Has Paternity (Fatherhood)
Been Established?
TO
g. Is There An Order For Support
Yes
No
ABSENT PARENT INFORMATION OR PARENT ORDERED TO PAY CHILD SUPPORT
GREETINGS:
Name
Absent Parent #1
Absent Parent #2
Absent Parent #3
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
at the
Court
located at
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
or adjourned date, to testify and give evidence as a witness in this action on the part of the
Address
the Honorable
(City, State, Zip Code)
SSN
Date of Birth (DOB)
Name of Employer
Address of EmployerYour
(City, State, Zip Code)
failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
Amount of Support Ordered
result of
(Wk, Bi-Wk, Mo) your failure to comply.
Case Number on Support Order
Witness, Honorable
County,
, one of the Justices of the
Date of Court Order
Support in
day of
, 20
Location Where Order Was Issued
(City, County, State)
Military Service
Give Date and Branch Entered
(Attorney must sign above and type name below)
Arrest Record: Give Date and Place
of Arrest
If the absent parent has been on Public
Assistance: Give Date and Place
Attorney(s) for
Give Name and Address of Current
Spouse of Absent Parent
q
Have you ever been on public assistance?
When (Date)
Yes
Where (City and State)
No
County
Office and P.O. Address
FOR AGENCY USE ONLY
Case Name
Case Number
Telephone
Date Requested
No.:
Facsimile No.:
E-Mail Address:
Date Returned or File Date
Mobile Tel. No.:
Date Mailed or Provided
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