APPLICATION FOR CHILD SUPPORT SERVICES 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 receive ADC or Medicaid. I the undersigned, Agency. I understand and agree to the following conditions: request Child Support Services from the County Child Support 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. The agency can assist in finding where an absent parent is currently living, in what city, town or 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 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 assist in collecting back support (arrearages) by intercepting a non-payor's federal and state income tax refunds on some cases. 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. 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. If you received ADC in the past and support was assigned to the state, back support collected will be paid to the state 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. The only fee you can be charged for services is a one dollar application fee. Some counties pay this fee for the applicants. D. 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. APPLICANT INFORMATION (INFORMATION ABOUT YOU) Name Date of Birth Social Security Number (SSN) Current Marital Status (Check One) Single Deserted Type(s) of Service(s) Requested: All services listed Other (please explain) Married Widowed Divorced Separated 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 has been accepted for child support services (IV-D Services). Signature of Applicant JFS 07076 (Rev. 5/2001) (Formerly DHS 7076) Date American LegalNet, Inc. www.USCourtForms.com Applicants Name (Last, First, Middle) Telephone Number (Home) Address (Street/Route, P.O. Box) (Work) City, State, Zip Code INFORMATION ON CHILDREN Child 1 Child 2 Child 3 Child 4 a. Name b. Sex c. SSN d. Date of Birth (DOB) e. Name(s) of Absent Parent f. Has Paternity (Fatherhood) Been Established? g. Is There An Order For Support Yes No ABSENT PARENT INFORMATION OR PARENT ORDERED TO PAY CHILD SUPPORT Absent Parent #1 Absent Parent #2 Absent Parent #3 Name Address (City, State, Zip Code) SSN Date of Birth (DOB) Name of Employer Address of Employer (City, State, Zip Code) Amount of Support Ordered (Wk, Bi-Wk, Mo) Case Number on Support Order Date of Support Order Location Where Order Was Issued (City, County, State) Military Service Give Date and Branch Entered Arrest Record: Give Date and Place of Arrest If the absent parent has been on Public Assistance: Give Date and Place Give Name and Address of Current Spouse of Absent Parent q Have you ever been on public assistance? When (Date) Yes No County Where (City and State) FOR AGENCY USE ONLY Case Name Date Requested Case Number Date Returned or File Date Date Mailed or Provided American LegalNet, Inc. www.USCourtForms.com