Application For Title Iv-D Child Support Enforcement Services
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4STATE OF CONNECTICUT
F0699N
DEPARTMENT OF SOCIAL SERVICES
(Rev. 6-11)
Page 1 of 4
BUREAU OF CHILD SUPPORT ENFORCEMENT
APPLICATION FOR TITLE IV-D CHILD SUPPORT ENFORCEMENT SERVICES
INFORMATION ABOUT YOU
First
M.I.
Last
Maiden
Name
(if applicable)
Street and No.
A pt. No.
City/ Town
State
Zip Code
Addres s
*
Date of birth
Soc. Sec. No.
Sex
Race
Marital Status
V ital
Information
M
F
Home Phone
Work Phone
Cell Phone
E-Mail
(
)
(
)
(
)
Full name
Dates of employment
Telephone Number
Employer
(
)
Employer’s
Street and No.
City/ Town
State
Zip Code
Addres s
If married, date and place
To whom?
Date separated (if applicable)
Relationship to obligor
If divorced, when?
Where?
Where?
If not divorced, have proceedings
begun? Select
Where?
When?
Case name
Ever received child
Select
Support services?
Where?
When?
Case number
Ever received public
Select
A ssistance/ Medicaid?
INFORMATION ABOUT THE CHILDREN OF THE NONCUSTODIAL PARENT
(Please include a copy of the birth certificate for each child.)
Name
Date
* Social
Issue of
Paternity
How (acknowledgment or adjudication)
Living with
of
security
marriage?
established?
and where (city, state, hospital) was
You?
birth
number
(Yes/ No)
(Yes/ No)
paternity established?
(Yes/ No)
Select
Select
Select
Select
Select
Select
Select
Select
Select
Select
Select
Select
Select
Select
Select
*
Providing your social security number, and the social security numbers of your child(ren), is required under federal law (42 U.S.C. 405
(c)(2)(C) and 42 U.S.C. 666) to administer the Connecticut child support program under CGS §17b-179. These social security
numbers will only be used to provide child support services to you and your family.
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