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Application For Child Support Services Form. This is a Oklahoma form and can be use in District Court Statewide.
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Tags: Application For Child Support Services, Oklahoma Statewide, District Court
*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)
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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.
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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
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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?
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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
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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
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Middle
First
Middle
City
Phone
State
City
Area code
Zip code
Area code
Phone
State
Zip code
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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?
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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
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Mother
Other person
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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
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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
$
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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
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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
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First
Middle
City
No
Yes
No
Phone
State
Zip code
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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.
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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
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