American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com PETITION TO MODIFY CHILD SUPPORT Names Birthdates American LegalNet, Inc. www.FormsWorkFlow.com PURSUANT TO APPLICATION FOR EXTRAORDINARY PROCESS IN THIS CAUSE. American LegalNet, Inc. www.FormsWorkFlow.com To request an ADA accommodation, please contact Dart Gore at 880 - 3309. American LegalNet, Inc. www.FormsWorkFlow.com STATE OF TENNESSEE DEPARTMENT OF HUMAN SERVICES APPLICATION FOR CHILD SUPPORT SERVICES It some important information regarding how your case will be handled. INFORMATION YOU NEED TO KNOW You must notify us immediately if you move or change your telephone number. Your cooperation is required. You must return any money sent to you in error. You must notify us in writing if you wish to cancel services. WE CAN ATTEMPT TO Locate a parent whose whereabouts are unknown, Establish paternity for a child, Establish and enforce court orders for child support payments, unpaid medical bills, and/or medical insurance, Review and modify child support orders, and Collect child support arrears using a variety of enforcement methods, including intercepting federal income tax refunds. WE CANNOT Guarantee that our attempts to establish or enforce child support will be successful, Handle matters that are not related to child support such as divorce, visitation or custody disputes, or Give your case priority over any other cases we have. AFTER WE RECEIVE YOUR COMPLETED APPLICATION, WE WILL Review your case, Decide the proper action to take on your case, and Make every effort to provide the needed service. IN ADDITION We will contact you if we need additional information from you, and to inform you of appointments and court hearing dates. Your signature on the application form indicates your agreement that the agency may file a legal action in your case and may close your case if you do not cooperate. Our attorneys represent the State of Tennessee. They will help provide you with child support services, but they do not represent you or any other individual. Case information will be given out only for child support purposes. All child support payments will be processed through the State Disbursement Unit in Nashville, Tennessee. American LegalNet, Inc. www.FormsWorkFlow.com HS-2912 (Rev. 12/14) RDA pending Page 1 State of Tennessee Department of Human Services Information Gathering Letter In accordance with federal law and U.S. Department of Health and Human Services (HHS) policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, contact HHS. Write HHS, Director, Office for Civil Rights, Room 506-F, 200 Independence Avenue, S.W., Washington, D.C. 20201 or call (202) 619-0403 (Voice) or (202) 619-3257 (TTY). HHS are equal opportunity providers and employers. You may also write Tennessee, DHS, Civil Rights Compliance Officer, Citizens Plaza Building, 400 Deaderick Street 15th Floor, Nashville, TN 37243, (615) 313-4748. NOTE: Each individual's Social Security number (SSN) is a critical part of case processing. Based on section 466(a)(13) of the Social Security Act [42 U.S.C. 666(a)(13)], you are required to disclose Social Security numbers to the child support agency. They will be used by the State's child support enforcement program to locate individuals for the purposes of establishing paternity and establishing, modifying, and enforcing support obligations. It is possible that your SSN and those of the child(ren) will be used to file interstate child support enforcement actions and to enroll the child(ren) as beneficiaries ecessary to properly identify that parent for the purpose of locating him/her, for submitting cases for the Treasury Offset Program, and for other child support enforcement activities. The information requested in this application must be provided by every applicant for child support services, regardless of whether they are the primary residential parent / caretaker or the alternate residential parent of the child(ren). If you are the primary residential parent (PRP) / caretaker, enter information about yourself in Section II and enter information about the alternate residential parent in Section III. If you are the alternate residential parent (ARP), enter information about the primary residential parent / caretaker in Section II and enter information about yourself in Section III. If you were married when the child(ren) was born, or when the child(ren) was conceived, or within three hundred (300) days after the marriage was terminated for any reason, Tennessee law states your husband is the legal father of your child(ren), and he will be pursued for child support. I. INFORMATION ABOUT THE APPLICANT FOR CHILD SUPPORT SERVICES 1. Are you The PRIMARY RESIDENTIAL PARENT (PRP) / CARETAKER of the child(ren) for whom services are requested (The PRP is the parent with whom the child(ren) resides more than 50% of the time) NOTE: For the purpose of completing this application, also check this box if the child(ren) for whom you are requesting services resides/reside with you exactly 50% of the time. or The ALTERNATE RESIDENTIAL PARENT (ARP) of the child(ren) for whom services are requested (The ARP is the parent with whom the child(ren) resides less than 50% of the time) If you are the ALTERNATE RESIDENTIAL PARENT (ARP), are you applying for A review and modification of your support order, or To establish paternity for the child(ren)? NOTE: Any application for child support services will result in this agency taking action as needed to enforce support obligations. 2. Are you under age 18 and unmarried? Yes No If yes, provide the following information about your parent or guardian: Last Name: First Name: Middle Name: Address: City: State: Zip: Phone (Home): () (Cell): () (Work): () 3. Do you have reason to believe that the ARP might try to harm you or the child(ren) if we try to contact him/her, or as the result of any action we might take on your child support case? Yes No If yes, please attach documentation, such as Police Report, Order of Protection, etc. F OR STATE USE ONLY Foster care worker name: Phone: Approval date: Social Services Number: IVE Case Number: American LegalNet, Inc. www.FormsWorkFlow.com HS-2912 (Rev. 12/14) RDA pending Page 2 II. INFORMATION ABOUT THE PRIMARY RESIDENTIAL PARENT (PRP) / CARETAKER If you are the primary residential parent (PRP) or caretaker of the child(ren), provide the following information about yourself. If you are the alternate residential parent (ARP), complete this section with information about the primary residential parent (PRP) / caretaker. 1. Last Name: First Name: Middle Name: Maiden Name: 2. en) (mother / father / grandmother / etc.)? 3. Identifying information for the primary residential parent (PRP) / caretaker Date of Birth: // Social Security Number: -- Sex: Email Address: Would you like to opt in to Email Messaging: Yes No Address of the primary residential parent (PRP) / caretaker MAILING address: City: State: Zip: County: Phone (Home): () (Cell): () (Work): () Would you like to opt in to Text Messages? Yes No If YES, which number do you want associated with Text Messages? Home Cell LIVING address: City: State: Zip: County: How do you prefer your caseworker to contact you? Mail Email Home Cell Work 4. Address: Phone: () City: State: Zip: 5. Has the primary residential parent (PRP) / caretaker ever been married to the alternate residential parent (ARP)? Yes No If yes, provide any of the following information that applies: Marriage Date: County: State: Divorce Date: County: State: Separation Date: County: State: 6. Is any other agency or attorney involved in pursuing child support at this time? Yes No If yes, give the name of the agency/attorney: Phone number: () Address: City: State: Zip: Has there ever been ANY legal action involving this child(ren)? Yes No If yes, describe the action: Answer questions # 7 and 8 only if you are the primary residential parent (PRP) / caretaker of the child(ren) 7. Do you currently receive, or have you ever received Medicaid benefits? Yes No Do