Division Of Welfare And Supportive Services Application For Assistance (Page 9 of 14) in pdf

NEVADA STATE DIVISION OF WELFARE AND SUPPORTIVE SERVICES

NON-CUSTODIAL PARENT (NCP) FORM

Complete one form for each parent who does not live with the child(ren) for whom you are requesting assistance. For

example, if you have two children and each have a different father / mother, you need to complete two forms. If you

are not the parent of the child(ren) you are requesting assistance for, you need to complete one form for the absent

mother and one form for the absent father. Do not leave any question blank. Write or type unknown or N/A (not

applicable) for any question that does not apply or you do not know the answer.

YOUR NAME:

YOUR SSN:

YOUR DOB:

YOUR RELATIONSHIP TO THE

CHILD(REN):

Have you or the children received public

If YES, where?

(City, State)

assistance in the past?

YES

Fill in whatever you know about the Non-Custodial Parent. If you do not know the answer to the question, write unknown or N/A.

LAST NAME:

FIRST NAME:

MIDDLE INITIAL:

MODIFIER (Jr., Sr., etc.):

ADDRESS:

CITY:

STATE:

ZIP:

SOCIAL SECURITY NUMBER:

TELEPHONE / CELL PHONE:

BIRTH CITY AND STATE:

DATE OF BIRTH:

IF DECEASED, DATE OF DEATH:

IF DECEASED, PLACE OF DEATH:

DATE LAST SEEN OR CONTACTED:

IS HE OR SHE DISABLED?

YES

RACE:

SEX:

HAIR COLOR:

EYE COLOR:

WEIGHT:

HEIGHT:

AT ANY TIME WAS THE MOTHER MARRIED TO

DATE OF MARRIAGE:

PLACE OF MARRIAGE:

THIS NON-CUSTODIAL PARENT?

YES

DATE OF DIVORCE:

PLACE DIVORCE FILED:

IF MARRIED ARE THEY DIVORCED?

YES

WAS THE MOTHER MARRIED TO

ARE THERE OTHER POSSIBLE

SOMEONE ELSE?

YES

FATHERS?

YES

EXISTING CHILD SUPPORT COURT ORDER?

YES

CITY AND STATE

INFORMATION ON THE CHILDREN FOR THIS ABSENT PARENT:

Did the mother have

sexual relations with

another man (not

named above), during

Child’s

Child’s date

30 days before or

Social Security

Middle

of birth

after when pregnancy

Custody

Child’s Last Name

Child’s First Name

Number

Initial

(MM/DD/YY)

began for this child?

Month

YES

All cases for Temporary Assistance for Needy Families (TANF) must be referred for Child Support Enforcement. This

information is correct to the best of my knowledge. I have read the “Important Child Support Information” section found on the

eligibility application. I understand if I have intentionally withheld or misrepresented information, I could be disqualified from

receiving public assistance.

I declare under penalty of perjury that the information I have provided on this document is true to the best of my knowledge and

belief and that the statements contained herein are made for the purposes stated here, including but not limited to, obtaining

assistance in establishing parentage and/or an order for child support along with the collection of child support.

Your Signature:

Date Signed:

Division Of Welfare And Supportive Services Application For Assistance Page 9

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