*03EN001E-001* OKLAHOMA DEPARTMENT OF HUMAN SERVICES Child Support Enforcement Division Application for Child Support Services OFFICE USE ONLY Date requested: Request type: Phone Walk-in I. Mail Services requested. I request: Date sent: Internet IVR Full CSED services. Locate only services. II. Person applying for child support services. • I am the custodial person. I request services for the child(ren) who lives with me. Check one or both boxes. I seek child support from: the child(ren)'s mother. the child(ren)'s father. • I am the noncustodial parent. I request services for the child(ren) who lives with the custodial person listed in Section III. I request child support services because: III. Custodial person. All questions in this section pertain to the person with whom the child(ren) lives. Please print all information. Full legal name, last First Middle Maiden name/other names used Social Security number Date of birth Area code Daytime phone Area code Home phone Sex Race If Native American, what tribe? Male Female What is the relationship of the custodial person to the child(ren)? Name of person with legal custody Mailing address City Home street address City County State Zip code State Zip code E-mail address for daytime contact OKDHS revised 7-1-2007 03EN001E (CSED-1) 1 American LegalNet, Inc. www.FormsWorkflow.com 03EN001E (CSED-1) Application for Child Support Services If you are the custodial parent, where do you want your payments mailed? Home address Mailing address Employer's name Area code Employer's phone Employer's street address City State Zip code Is child(ren) receiving benefits, such as TANF or SoonerCare (Medicaid)? In what state are the benefits received? Yes No Is a private or government agency currently working on child support case? Yes Agency retained by: Custodial person Other No Name of agency Street address Area code City Phone State Zip code Is a private attorney currently working on the child support case? Private attorney retained by: Custodial person Other Name of private attorney Street address Yes No Phone City State Zip code IV. Family violence. Do you believe you or your child(ren) could be at serious risk of emotional or physical harm if the other parent knows where to find you? If so, you may request your location information be protected by Child Support Enforcement Division (CSED). To do so, you must complete Form 03EN008E, Family Violence - Address of Record Statement, and submit it with this application. To request Form 03EN008E, contact CSED at 405-522-2273 or TTY at 405-5223792 in the Oklahoma City calling area, 918-295-3500 in the Tulsa calling area, or toll free at 1-800-522-2922 or TTY at 1-866-264-4767. CSED uses Form 03EN008E to update your official address of record. Otherwise, under Oklahoma law, your physical location information may be released to the other parent or person on your case. Address of record. An address of record is a public address where you will accept payments and legal and other official papers by regular mail, such as your private attorney's address, if you have one. This address will be printed in legal/court documents and, therefore, may be provided to the other parent or person on your case. If family violence is an issue, this address of record must be different from a home address. 2 OKDHS revised 7-1-20007 American LegalNet, Inc. www.FormsWorkflow.com Application for Child Support Services 03EN001E (CSED-1) V. Information about the parent(s). Please print all information. Father or person who may be the father, if not the custodial person. Full legal name, last Father's present State Zip code First Middle Other names used or last known street address Area code Father's City County present or last known phone number Is father currently married? Yes No Employer's name Current If yes, father's spouse's full name? Last known Area code Employer's phone Employer's street address City State Zip code Usually employed as a (plumber, mechanic, fast food) Does father have an occupational license, such as doctor or electrician? Yes If yes, what kind? No Does the father have a lifetime hunting or fishing license? Yes No Does the father belong to a union? If yes, what is the name and address of the union? Yes No Yes No Union name Address Are there any pending lawsuits or claims for money? Is yes, please explain. Father's description. Photograph attached? Yes No Date of photograph: Birthplace, City State Date of birth Social Security number Race If Native American, what tribe? Hair color Eye color Has father been in jail or prison? When? Location, City OKDHS revised 7-1-2007 Height Weight Identifying marks, such as scars or tattoos Yes No State 3 American LegalNet, Inc. www.FormsWorkflow.com 03EN001E (CSED-1) Application for Child Support Services Has father been on probation or parole? Yes No Name of parole or probation officer and city and state Is father retired? Yes No Yes No Where did he work when he retired? Is father disabled? Is father employed by the state of the federal government, agency of the tribal government of the military, branch of Information about the father's vehicle. Year of vehicle Make Model Color License plate number State Does father own any property or assets? If yes, list below. Real estate Yes No City County State Registered vehicles, other than the one listed above Name and address of financial institution and account numbers Other possessions of value, such as stocks, bonds, jewelry, pensions, or gun collections Information about the father's parents. Mother's last name First Street address Father's last name Street address Middle First Middle City Phone State City Area code Zip code Area code Phone State Zip code What else can you tell us that may help us locate the father? 4 OKDHS revised 7-1-20007 American LegalNet, Inc. www.FormsWorkflow.com Application for Child Support Services 03EN001E (CSED-1) Mother, if not the custodial person. Legal last name Mother's State First present or Zip code Middle Maiden/other names used last known street address Area code Is mother currently married? Yes No Employer's name Current City Mother's present County or last known phone number If yes, mother's spouse's full name Last known Employer's street address Area code City State Employer's phone Zip code Usually employed as a waitress, office worker, or fast food Does mother have an occupational license, such as beautician or doctor? If yes, what kind? Yes No Does mother have a lifetime hunting or fishing license? Yes No Does mother belong to a union? If yes, what is the name and address of the union? Yes No Yes No Union name Address Are there any pending lawsuits or claims for money? If yes, please explain. Mother's description. Photograph attached? Yes No Date of photograph: . Birthplace, City State Date of birth Social Security number Race If Native American, what tribe? Height Hair color Eye color Identifying marks, such as scars or tattoos OKDHS revised 7-1-2007 Weight 5 American LegalNet, Inc. www.FormsWorkflow.com 03EN001E (CSED-1) Application for Child Support Services Has mother been in jail or prison? Yes When? No Location, City State Has mother been on probation or parole? Yes No Name of parole or probation officer and city and state Is mother retired? Yes No Yes No Where did she work when she retired? Is mother disabled? Is mother employed by the state of the federal government, agency of the tribal government of the military, branch of Information about the mother's vehicle. Year of vehicle Make Model Color License plate number State Does mother own any property or assets? If yes, list below. Real estate Yes City No County State Registered vehicles, other than the one listed above Name and address of financial institution and account numbers Other, possessions of value, such as stocks, bonds, jewelry, pensions, or gun collections Information about the mother's parents. Mother's last name First Street address Father's last name Street address 6 Middle First Middle City Phone State City Area code Zip code Area code Phone State Zip code OKDHS revised 7-1-20007 American LegalNet, Inc. www.FormsWorkflow.com Application for Child Support Services 03EN001E (CSED-1) What else can you tell us that may help us locate the mother? VI. Information about the child(ren). Information in this section concerns the child(ren). Please print all information. List only those children belonging to the same mother and father. A child(ren) of a different set of parents requires a separate application. Legal last name of child Social Security number First Middle Date of birth If Native American, what tribe? Was the child born in Oklahoma? Yes No Sex Race Male Female Estimated high school graduation date If no, where was the child born? Legal status: Support ordered for this child. Paternity established, no support ordered. Paternity needs to be established legally. Parents married, living apart, no support ordered. Legal last name of child Social Security number First Middle Date of birth If Native American, what tribe? Was the child born in Oklahoma? Yes No Sex Race Male Female Estimated high school graduation date If no, where was the child born? Legal status: Support ordered for this child. Paternity established, no support ordered. Paternity needs to be established legally. Parents married, living apart, no support ordered. Legal last name of child Social Security number First Date of birth If Native American, what tribe? Was the child born in Oklahoma? Yes No OKDHS revised 7-1-2007 Middle Sex Race Male Female Estimated high school graduation date If no, where was the child born? 7 American LegalNet, Inc. www.FormsWorkflow.com 03EN001E (CSED-1) Application for Child Support Services Legal status: Support ordered for this child. Paternity established, no support ordered. Paternity needs to be established legally. Parents married, living apart, no support ordered. What amount is paid for child care to allow the custodial person to be employed or attend school? Amount $ Check one: Weekly Biweekly Monthly VII. Information about the child support obligation and custody of the children. Please print all information. What is the current relationship between the mother and father of the child(ren)? Never married Married/living apart Date of marriage ceremony Divorced County State Provide a copy of any court order, such as divorce, paternity order, custody order, or tribal order. Attach a copy to this form. If you do not have a copy, fill in the blanks below. Date of court order Court case number If tribal court, what tribe? County State Court Where? Are there any legal actions pending that affect the child(ren)? Check all that apply: Visitation Custody Other Yes If yes, provide a copy and fill in the blanks below. Date of filing Case number County State Court If child support has been ordered, how much is the noncustodial parent ordered to pay? $ How often? Have there been any changes to the child support order? If yes, provide a copy Yes No Date of changes: What were the changes? Use the space on page 7 to record additional information. Health insurance coverage. Who is the provider of the health insurance? Father 8 Mother Other person OKDHS revised 7-1-20007 American LegalNet, Inc. www.FormsWorkflow.com Application for Child Support Services 03EN001E (CSED-1) Is the child(ren) enrolled in a health insurance plan? If yes, which child(ren) is enrolled? Yes No What is the cost per month to cover only the child(ren)? $ Name of insurance company Effective date Street address of insurance company State Health insurance group number City Area code Phone Zip code Policy number Does the child(ren) receive medical services from an Indian health agency? Yes No Child support payments. Please send me an access code so that I can obtain child support payment information over the telephone or the Internet. After submitting your application you must forward to CSED all support payments you receive from anyone other than CSED. Mail payments to: Oklahoma Centralized Support Registry P.O. Box 268849 Oklahoma City, OK, 73126-8849 The CSED Web site is http://www.okdhs.org/programsandservices/cse/. Additional comments: OKDHS revised 7-1-2007 9 American LegalNet, Inc. www.FormsWorkflow.com 03EN001E (CSED-1) Application for Child Support Services VIII.Statement of child support payments received. If more than one parent has paid child support, copy this page and complete one for each parent. Office use only Court case no.: OK IV-D case no.: Custodial person name Noncustodial parent name Child's name Child's date of birth Child's name Child's date of birth Child's name Child's date of birth 1. I, in the amount of $ 2. , state that child support . per month is due from I, , have received no child support from the noncustodial parent. Do not fill out the remainder of the form. Please sign and date the form. OR 3. I, , have received child support payments from the noncustodial parent as shown below. List all child support payments below. Month Year: Month Year: Month Year: Jan Feb $ $ Jan Feb $ $ Jan Feb $ $ Mar $ Mar $ Mar $ Apr May $ $ Apr May $ $ Apr May $ $ Jun $ Jun $ Jun $ July Aug $ $ July Aug $ $ July Aug $ $ Sep Oct $ $ Sep Oct $ $ Sep Oct $ $ Nov $ Nov $ Nov $ Dec $ Dec $ Dec $ 10 OKDHS revised 7-1-20007 American LegalNet, Inc. www.FormsWorkflow.com Application for Child Support Services 03EN001E (CSED-1) Month Year: Month Year: Month Year: Jan Feb $ $ Jan Feb $ $ Jan Feb $ $ Mar $ Mar $ Mar $ Apr May $ $ Apr May $ $ Apr May $ $ Jun $ Jun $ Jun $ July Aug $ $ July Aug $ $ July Aug $ $ Sep Oct $ $ Sep Oct $ $ Sep Oct $ $ Nov $ Nov $ Nov $ Dec $ Dec $ Dec $ 4. The following is an explanation regarding the period(s), if any, for which support may be due but no request is being made to collect: I state under penalty of perjury under the laws of Oklahoma that the foregoing is true and correct. Signature of custodial person OKDHS revised 7-1-2007 Date and place 11 American LegalNet, Inc. www.FormsWorkflow.com 03EN001E (CSED-1) Application for Child Support Services IX. Paternity questionnaire. Skip this section if paternity is not in question. Complete one paternity questionnaire for each child. Please print all information. Information about the mother of the child. Legal last name First Middle Date of birth Currently pregnant? Yes No If yes, who is the biological father? When is the baby due? Information about the child. Legal last name First Middle Date of birth Was the child conceived in the state of Oklahoma? Yes No If no, what state? Has a voluntary acknowledgment of paternity form been signed on child? Yes If yes, date completed: If yes, what state? Provide a copy. No Has the acknowledgment been withdrawn? If yes, date withdrawn: Yes No Has genetic testing to determine paternity been conducted for this child? Yes If yes, please explain. No If father lives outside Oklahoma, has he ever lived or worked in Oklahoma? Yes No Has he lived in Oklahoma? Yes No When and where? Has he worked in Oklahoma? Yes No When and where? Information about the mother's relationship with the alleged biological father. Has the alleged biological father ever paid any bills for this child? If yes, attach a list of dates and amounts. Keep the receipts, if any. Yes Did the mother have a sexual relationship with anyone other than the alleged biological father within 90 days before or after the date the mother became pregnant with this child? Last name of this person Mailing address 12 First Middle City No Yes No Phone State Zip code OKDHS revised 7-1-20007 American LegalNet, Inc. www.FormsWorkflow.com Application for Child Support Services 03EN001E (CSED-1) Has any other person been named as the father of this child? Yes No If yes, person's full name Information about the mother's husband when the child was born. Please complete this section if the mother had a husband at the time of this child's conception or birth and the husband is NOT the father of the child. Legal last name First Address: present Middle Other names used Zip code Phone number or last known Street address City State Husband's description. Date of birth Birthplace Social Security number Race Height Weight Hair color Identifying marks, such as scars or tattoos Current employer's name Area code Employer's phone What is the current relationship between the husband and the mother of the child? Married Divorced date of divorce: Married/Separated Type of marriage Common-law Licensed Has a court order stated the ex-husband is not the father? Yes No Attach a copy of all orders. X. Comments. Please write any comments you may have. OKDHS revised 7-1-2007 13 American LegalNet, Inc. www.FormsWorkflow.com 03EN001E (CSED-1) Application for Child Support Services XI. Signature required. By signing this application, I authorize CSED to: • take child support establishment and enforcement action CSED finds appropriate; and • endorse and negotiate payments related to child support and spousal support, including checks, money orders, bank drafts, and electronic payments on my behalf and on behalf of the child(ren) in my case, if I am the custodial person. I understand: • CSED and others may use the address I provide for service of papers; • the post office does not forward child support payments to a new address I have provided them. I must inform CSED of my new address in order to receive my child support payments, and court and other legal documents; • CSED attorneys and staff do not represent me; • if I receive support to which I am not entitled, I must pay it back. CSED may hold back all or a portion of my support payments to recover what I owe; and • the penalty for perjury on a document that will be used in a judicial proceeding is five years in prison and a $1,000 fine. I read and understand the Child Support Services and Responsibilities at the beginning of this application. Further, I state under penalty of perjury under the laws of Oklahoma that the foregoing is true and correct and that all of the information I have given, particularly information that relates to all individuals who might be the father of the child(ren), is true and correct. I acknowledge the truth of all information provided in all sections in this information packet. I understand this acknowledgment applies to the information packet as a whole and to each individual section. Signature of applicant Date and place Did you: • • • • sign this application (Form 03EN001E)? make a copy of this form for your records? enclose a copy of all court orders? send this application and court orders to: Oklahoma Centralized Support Registry P.O. Box 268876 Oklahoma City, OK 73126-8876 14 OKDHS revised 7-1-20007 American LegalNet, Inc. www.FormsWorkflow.com