APPLICATION FOR CHILD SUPPORT SERVICES (Existing Dane County Court Case Only) If you are involved in a family court action in Dane County, and have children, you may use this form to apply for services from the Dane County Child Support Agency. There is NO APPLICATION FEE for our services. We can assist you with the following: Collect court ordered child support through income withholding Enforce the payment of unpaid support through tax refund intercept, liens, license suspension and other administrative processes. You can get more information about the child support program at www.danechildsupport.com. If you are interested, please complete and return the application form below and attach a copy of your most recent court order (if any): Dane County Child Support Agency Room 365 210 Martin Luther King Jr. Blvd. Madison WI 53703 Please note the following regarding Child Support services: Child support agencies DO NOT handle child custody or physical placement (visitation) issues. A Child Support attorney who appears at your hearing represents the State of Wisconsin, not you. Applying for services does not create an attorney-client relationship with the Child Support attorneys. If you have a percentage­expressed child support order, and you apply for child support services, the agency is required by state law to ask the Court to change your order to a fixed dollar amount. If the agency collects support arrears through tax refund intercept and the refund is recalled, you will have to return the payment. If a tax intercept collection is at least $10, a fee of 10%, up to $25, will be deducted from the collection. ______________________________________________________________________________________________ Application for Child Support Services Applying for: Child Support Enforcement Establish Paternity (legal fatherhood) Health Insurance Yes, I _____________________________________ want Dane County Child Support Agency services. (Please print your name clearly) I am ordered to PAY support RECEIVE support provide health insurance PENDING­divorce not finalized My address: _____________________________________________________________________________ (Street) (City) (State) (Zip) My Date of Birth: __________________ My Social Security Number: ______________________________ Phone: Home ______________________ Work _________________ Dane County Court Case Number ____________________ Health insurance for child(ren)? Health insurance provided under Yes No If yes, insurance company? _______________________ my policy other parent's policy Cell __________________________ Other Parent: _______________________________________ ________________ ____________________ First Middle Last Birth Date Social Security Number (if known) (if known) Address: _____________________________________________________ Phone #s: _________________ (Street) (City) (State) (Zip) Other Parent's Employer: _____________________________________________________ Child(ren) Names, Date of Birth and Social Security Numbers (if known): _____________________________________________________________________________________________________________________ ________________________________________________________________________________________ Signature: ______________________________________________ Updated 4/9/13 Date: ________________________ CCC American LegalNet, Inc. www.FormsWorkFlow.com