Form Csf 03 0574 - Application For Child Support Services Oregon Child Support Program Page 2
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4If you do not speak or read English, what language do you speak? ___________________________________
What language do you read? ________________________ Do you need an interpreter?
[ ] Yes
[ ] No
If the other party does not speak or read English, what language does he/she speak? ____________________
What language does he/she read? ______________ Does he/she need an interpreter?
[ ] Yes
[ ] No
The Child Support Program can provide you with information from forms and other notices in your own language
free of charge. This also includes Braille, large print, and the use of interpreters. To find out more, contact your
child support office.
A
@
Read #2 on the attachment and if you want to use a
contact address,
provide it below:
________________________________________________________________________________________
[
] I have been making/receiving support payments through an escrow agent and by my signature below,
authorize the Child Support Program to get copies of support payment information from the escrow
company.
Name of escrow company
Address
Phone number
Information about children of this relationship (
)
use additional sheets if necessary
Full name & sex (M or F)
Birth date
Soc. Sec. No.
/
/
/
/
/
/
Is there health care coverage for the children? [ ] Yes [ ] No
If yes: Who is policy holder? [ ] Non-custodial parent [ ] Custodial parent [ ] Other
Insurance Company
Policy number
Address
Phone number
Has the custodial parent or the child(ren) ever received cash assistance in any state?
[ ] Yes [ ] No
If yes, what state?
Who received the cash assistance?
Dates:
to
I certify that the above information is true and correct to the best of my knowledge and belief.
Signature:
Date: __________________________
Page 2 of 4 - APPLICATION FOR CHILD SUPPORT SERVICES
CSF 03 0574 (Rev. 11/07/12)
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