Application For Title Iv-D Child Support Enforcement Services Page 4
Download a blank fillable Application For Title Iv-D Child Support Enforcement Services in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Application For Title Iv-D Child Support Enforcement Services with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4F0699N
(Rev. 6-11)
Page 4 of 4
INFORMATION ABOUT YOUR RIGHTS
Information concerning your whereabouts can be protected from disclosure to the noncustodial parent
if: (1) you provide evidence that there is a protective or restraining order in effect against such parent,
or (2) we determine, based on information provided by you, that release of such information may result
in physical or emotional harm to you or your child.
If you believe that you have been treated unfairly because of race, color, religious creed, sex, sexual
orientation, age, national origin, ancestry, mental retardation, learning disability or physical disability,
you have the right to appeal to the Commissioner of Social Services, the Commission on Human Rights
and Opportunities, or the U.S. Department of Health and Human Services.
AGREEMENT AND AUTHORIZATION FOR RECEIPT OF IV -D SERV ICES
I hereby request Title IV -D child support services. I agree to cooperate with the Bureau of Child
Support Enforcement, and any cooperating agencies or contractors, and authorize them to use all legal
means necessary to provide requested services. I understand that if I begin receiving Title IV -D services,
child support payments by way of income withholding will be directed through the state disbursement
unit both while I receive such services and also when such services are terminated for any reason. I
understand that if child support payments are received that are greater than the amount due to me in
that month, and there are no amounts owed on any other obligations, only the amount that is due to me
will be paid. Remaining payments will be paid to me when an amount becomes due. I understand that a
fee of not more than $25.00 will be deducted annually from my child support payments for this case.
“ A nnually” means state fiscal year (July 1 through June 30). The fee will only be deducted from my
payments after I have received $500.00 in child support from the noncustodial parent, and the fee will
not be charged to me if I ever received cash assistance. I also understand that any child support
payments will be sent to me by electronic means, either by direct deposit into my bank account, or by a
debit card issued to me by the Department of Social Services. I certify that all information provided by
me in this application form is true and complete to the best of my knowledge and belief.
Please check one of the boxes at the end of this paragraph to indicate that you consent or do not
consent to automatic withholding, without further notice, from any future support payments collected
on your behalf of amounts paid to you (1) in error or (2) on the basis of a check received from the
noncustodial parent and returned by a financial institution for insufficient funds. You can receive Title
IV -D services even if you do not consent to such withholding. However, if you do not consent to such
withholding, the Bureau of Child Support Enforcement, and any cooperating agencies or contractors,
will seek recovery of any amounts paid to you as described above using all legal remedies available to
them. (If neither of the following boxes is checked, it will be presumed that you have provided your
consent.)
I cons ent to s uch withholding.
I do not cons ent to s uch withholding.
Applicant's Signature
Date
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Csed 04-1017 - Application For Child Support Enforcement Services And Affidavit Of Support Received And Affidavit And Request For Address Confidentiality - Alaska Division Of Child Support Enforcement
Legal
Application For National Visa (d) Filing Sample - Consulate General Of Italy, Boston, Massachusetts, Usa
Business
Related Categories
Parent category: Legal