Form Csed 04-1603 - Child Support Information Form printable pdf download

OFFICE USE ONLY: check one:

MED only

DPA Case No.

CHILD SUPPORT INFORMATION

PLEASE FILL OUT A SEPARATE INFORMATION SHEET FOR EACH ABSENT PARENT

(Please print)

THE INFORMATION YOU PROVIDE BELOW WILL BE USED TO SET UP AND ENFORCE CHILD SUPPORT. PLEASE READ THE FORM “WHAT THE

CHILD SUPPORT ENFORCEMENT DIVISION (CSED) CAN DO FOR YOU” BEFORE YOU FILL OUT THIS FORM.

Your Name:

SSN:

Address:

City/State/Zip Code:

Telephone:

Absent Parent’s Full Legal Name:

SSN:

Your Relationship to child(ren)

( ) Father ( ) Mother

( ) Other _______________________________________

SUPPLYING INFORMATION TO CSED AND APPLYING FOR A GOOD CAUSE EXEMPTION

You are required by law to give CSED information to get child support for a child receiving Temporary Assistance or medical assistance. This

means you will be asked to give CSED the name of the absent parent and information you have about where he/she lives or works. You

must also help CSED establish paternity if the child does not already have a legal father. Any money you receive from the absent parent for

child support must be given to CSED.

If you believe that having a child support case will harm you or your child(ren), and you can provide evidence to support this belief, you may

claim good cause by marking the 3

box below. You will be asked by your caseworker to fill out the Good Cause claim forms.

If you want to cooperate with CSED in getting child support, but you are afraid that you or your child(ren) would be harmed if the absent

parent was given your address, you may ask CSED to keep your address confidential by filling out the information on page four.

You must either cooperate with CSED or have good cause not to cooperate. If you do not cooperate or have good cause, your

Temporary Assistance payment will be reduced and your family’s Temporary Assistance will be paid to another person called a

“protective payee”.

(

) I AGREE TO COOPERATE WITH CSED (Complete pages 1-3 of this form.)

(

)

I WANT TO COOPERATE WITH CSED IN GETTING CHILD SUPPORT BUT I WANT TO KEEP MY ADDRESS

CONFIDENTIAL. If medical support is obtained through the absent parents health insurance, he or she may receive

information about health insurance claims submitted on behalf of the child(ren).(Complete pages 1-4 of this form.)

(

) I WANT TO APPLY FOR A GOOD CAUSE EXEMPTION FROM SUPPLYING INFORMATON TO CSED. (Do not complete the

rest of this form.)

________________________________________________________________

_______________________________

Signature

Date

INFORMATION FROM CHILD’S BIRTH CERTIFICATE:

Child's

Father’s

Date of

Place of

State where child

Name

Birth

was conceived

CSED 04-1603 (Rev 09/13/00)

Page 1 of 4

Form Csed 04-1603 - Child Support Information Form

Related Articles

Related forms

Related Categories