Application For Child Support Services Page 2
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2Form MDHS-CSE-675
Revised 09-01-14
Page 2
Email:
Mailing Address:
Home Address:
Employer Name and Address:
Telephone Number: Home:
Work:
Cell:
Relationship to other parent: Divorced ☐ Married ☐ Never Married ☐ Separated ☐ Never Married-Paternity Established ☐ Other ☐
Under the penalty of perjury I do hereby swear and affirm that the information I provided on this Application for Child Support Services is accurate
and true to the best of my knowledge. I authorize the Mississippi Department of Human Services, Division of Field Operations (DFO) to perform the
following:
Locate the noncustodial parent;
Establish the legal paternity of my child(ren);
Get a legal order for child support, including medical insurance, for the child(ren), or get an amendment to the child support order if one
already exists;
Enforce the child support order by any way permitted by law;
Collect and distribute child support payments according to Federal guidelines and the laws of the State of Mississippi;
Disclose my circumstances in pleadings or other documents filed in a proceeding to enforce/determine child support for my child(ren). I
understand that I am entitled to a determination of good cause if my or my child(ren)’s health, safety or liberty would be unreasonably put
at risk if information concerning my circumstances is disclosed as stated above.
I understand that:
I have assigned to DFO any and all rights and interests in any cause of action past, present, or future that I or the child(ren) included in this
application may have against any parent failing to provide for the support of the minor child(ren);
A non-refundable fee of $25 will be charged as an application fee and to recover the costs of any services performed for applicants who are
not receiving public assistance [Temporary Assistance for Needy Families, (TANF) or Supplemental Nutritional Assistance Program
(SNAP)]. No action will be taken until the application fee is paid;
There may be additional fees necessary, such as: court costs, filing fees, service of process fees;
DFO does not guarantee that efforts on my behalf will be successful;
If I do not cooperate with DFO, my case may be closed after advance notice, and the child care provider notified (if applicable);
I understand the criminal penalties for making false statements and false swearing and do hereby attest to the truthfulness of the
information provided. [False swearing is punishable by a fine of not more than $1,000 or by imprisonment of one year or both.];
If I have an existing support order, upon paying the application fee for child support services, payments will be automatically directed to
DFO. Upon my request to close my child support case, it is my responsibility to have the payments redirected in court;
It is my responsibility to notify DFO of any direct payments I receive from the noncustodial parent or any subsequent child support orders I
obtain;
If I receive any money that was sent to me in error, the overpayment must be repaid by me;
The state staff attorney and/or private contract attorney providing services pursuant to this application for child support services:
o
Does not represent me in any actions which may occur.
Represents only the state and the state’s interest.
o
o
Cannot give me any legal advice; further, I understand that if I want legal advice I should contact my own attorney.
o
Does not deal with custody or visitation rights.
That any monies herein paid by me are not attorney fees;
I and/or the other parent each have the right to request a review, in writing, of the support obligation every three years to ensure the amount
is appropriately based on established guidelines, and this review may result in an increase or decrease in the child support obligation; and,
No fee will be charged for parent locate only cases;
I must apply for and cooperate with child support enforcement as a condition of eligibility for a child care certificate; and
I must notify DFO immediately when I have a change of address.
I have been notified by DFO that the child support worker who is handling my case will contact the noncustodial parent of my child(ren) and set up a
meeting with him/her to attempt to reach an agreement to pay child support. The amount of child support to be paid will be based on his/her income.
If I have any information that DFO should know prior to this meeting (such as the noncustodial parents’ income, employer, etc.), I must contact the
child support worker immediately. Otherwise, an agreement may be reached on the amount of child support to be paid based on other information,
including information the noncustodial parent tells the agent.
☐ I am claiming good cause and, if proven, do not authorize disclosure of my case information.
I request full services ☐ or locate only services ☐. (Check one.)
Applicant’s signature:
Date:
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